“He has been snoring since infancy,” was the complaint last week as I reviewed the chart of a teenage girl on 5 psychotropic medications, the first prescribed when she was 8 for depression. No wonder her blood pressure was through the roof and she could barely breathe while awake.  Her tonsils were so big I could hardly see anything else in her throat or understand her muffled speech. Unable to function, she has been home schooled for months.  Finally someone thought to check for sleep apnea.

“Oh, yeah, he always falls asleep in the car and in front of the TV and sometimes in school,” was a complaint the week before.

What’s the big deal about snoring?  Just a little kick in the side or an elbow in the back.  He turns over and quiets down.

Sleep apnea is epidemic.  The increase in incidence is due to a combination of greater awareness, greater numbers of children with enlarged tonsils and adenoids, change in eating habits with reflux of stomach contents causing the airways to close off for protection at night, and smaller airways (yes, our noses, oral cavities and throats are getting smaller over time.)

I don’t expect that every doctor will have the fund of knowledge to think about sleep apnea for every situation.  But I am becoming alarmed at how readily very young children are being treated for once rare psychiatric problems before organic causes of behavior and emotional problems are sought.

On the other hand, the range of “normal” behavior for kids has been so narrowed that more kids everyday come through my door with a “behavioral/emotional” diagnosis or on some behavior modification medication.  Yes, I am frustrated and I think parents are, too.

Some things you need to know:

• Not all the symptoms the child has might be from the sleep apnea, but many might.
• Not all the kids are obese.
• Not everyone snores loudly–sometimes the quietest noise is the most dangerous because hardly any air is moving at all
• The tonsils and adenoids are not always enlarged–they may be small and the child might still have a big problem.
• It can make other problems, like acid reflux, worse.  And other problems, like acid reflux or dental abnormalities, can make the sleep apnea worse.  Chicken or the egg–which comes first?

So my mixed and rambling message here is to think twice about putting your kid on medication for behavior.  And then think at least once that maybe sleep apnea is the problem.  Get the child tested.  Talk to your doctor.  Ask for a sleep study, in fancy medical lingo a PSG, a/k/a polysomnogram.

Sleep apnea in children is a challenge to diagnose and a greater challenge to treat.  But God knows, I am always up for a challenge.  If this post helps just one kid, I will be happy I wrote.

We met Dr. Barnes in the first weeks of gross anatomy. She was a general surgeon who came with her lab coat over her scrubs to teach the first year students surgical anatomy. Clinical correlations of the basic sciences was a regular part of our curriculum. The most important piece of information I took away from that course was how to establish an emergency airway.

That meant we had to know where find the cricoid cartilage in the neck. The cricoid cartilage is the hard “bump” in the neck. Well, just above that is a membrane called the crico-thyroid membrane. (Stay with me, this might save someone’s life, even yours, someday.)

“If someone’s airway is obstructed and they look as if they are going to die,” Dr. Barnes would say in her voice tinged with a slight Southern drawl, “that is, they are turning blue, you just have to take your BIC pen, remove the nib and ink cartridge. Then just poke the tip of the pen through the space above that cricoid cartilage. You will save a life, just with that simple BIC pen.”

Most of you might not even remember those plastic casings of a BIC pen from the 1970’s. But do you know that I carried a BIC pen with me all through medical school and residency, just in case. And then for years I carried an emergency mini-trach set that could be put in my purse. I never forgot Dr. Barnes’ admonition that we had to know our anatomy so we could save someone’s life. I never had that opportunity to do an emergency cricothyrotomy (even as an ear, nose and throat surgeon), but I have never forgotten what Dr. Barnes said, so I am sure I can do this with a BIC pen, or any other sharp, hollow object of similar size.

So when I saw that she had died this past year, I knew that an important person had passed from my life. She was a woman surgeon when there were only a handful in the whole country. I was blessed to have been taught by Dr. Barnes. Thanks for the memories.

What about those whose mother’s are no longer alive?  And what about those who don’t have children of their own either out of choice or from biological or social necessity? And what about the children whose mothers are alive but sadly no longer available to them because of a falling out or have succumbed to the ravages of dementia or drugs and alcohol?

I am sure there are no Hallmark cards for these mothers. And no comfort for the children to directly express gratitude.  And it’s the expression of gratitude that brings us the most satisfaction.  Being able to say “thank you,” and really mean it, is the basis for true happiness.

Unfortunately, I cannot take credit for this observation.  I first read about the link between happiness and gratitude in Dennis Prager’s, Happiness is a Serious Problem.  He also talked about the obligation to be happy.  This helps others live healthful lives.

The other book that is important on the subject was written by Robert Emmons, Thank you! How the New Science of Gratitude Can Make You Happier.  This more recent book addresses the neurophysiology of gratitude and how the biochemicals are those that cause feeling of happiness.

I hope that on this Mother’s Day you are at least able to say a prayer of gratitude for the gift of life that your mother gave to you.  She carried you for 9 months (in most cases) and if nothing else, half of your DNA is hers.  When we are not able to have the idealized relationship with our mothers (and conversely with our children), this small act of remembering might be enough to get you through this day with some small spark of warmth for someone special, more or less. Hopefully for most of you, more.

Making an impact beyond the people you touch in everyday life is challenging to say the least.  But the rewards far outweigh the challenge.  In academic medicine my mission was to touch lives of those I didn’t meet through research and teaching.  My message: keep asking and answering questions for the benefit of medical science and our patients.  My creation: the large body of work found in the articles and books I have published.

While I still keep a toe hold in the academic world, my creative energies have been re-directed.  I now help women physicians overcome unexpected career obstacles and deal with unpleasant medical politics so they can get the jobs they want, the pay they deserve and not become prisoners of their careers.  (Great elevator speech, yes?)

Beyond the mission, vision and message is a lot of hard work.  Being a creator, being an entrepreneur, being an “expert” takes a lot of training.  So I found myself a trainer.  Little did I know that thousands of others had found the same one. Brendon Burchard at Expert’s Academy , best selling author, speaker, coach, seminar leader and event planner par excellence.

I cannot say exactly how I got to Brendon Burchard, but once I was there, I knew that his message resonated with me and my next big creation–Women MD Resources.

Five days in the Santa Clara Marriott.  The intensity was amplified by the great orchestration of a program with superlative content.  It was delivered with a brilliance usually reserved for shows by rock stars. I invited my friend and co-creator Karen Skoog, RN, Case manager.  She helps the elderly and their families navigate the new world of “getting old” so that it is not so confusing or scary, and they don’t have to “figure it out” when illnesses or changes occur.  (This is NOT her elevator speech.  It is my paraphrase, so forgive me Karen.)

Thursday morning we lined up to get as close to the front of the ballroom which held 750 people.  The stampede was scary and a little off putting at first.  The music went along with the atmosphere of celebration for an event that was just beginning.  I soon realized that the well deserved hype was grounded in the many communications and teaching materials I had been studying for the last several months on line.  People were ready.  I was ready.

The stage was soon filled with a smile as large as they come.  Clapping  and moving to the music with such energy that we all had to join in as the frenzy increased.  And then we were quieted down and the teaching began–almost effortlessly but most effectively.

We are creators.  We have an important message to share with the world.  We inspire and instruct.  We should do it as professionals.  We should each find our voice.  And we did over the next 4 days from 9 am to 9 pm (last day to 3 pm).  We broke into multiple small groups and listened and spoke.  We helped each other fine tune messages and speak with ease.

I was sad when Sunday afternoon rolled around so soon.  The magic lingered through seeing our daughter Dana, dinner and the red eye to finally get into Buffalo the next morning.

And now the hard work begins.  I have the road map before I go down the road too far.  No doubt there are many lessons more to learn, but I have enough to get where I need to go next.  I hope you will join me.  Soon we will launch and take off for who knows where.  Thanks Brendon.

My life of late has been anything but dull. Last week was very busy in the office and this week I had three great days seeing patients and operating. In between, I had a quiet weekend on call—in 96 hours of carrying my pager, wearing it to bed in vibrate mode so as not to wake up hubby. I received only 7 calls and none in the middle of the night! You cannot imagine how good that felt.

Two conference calls: finance committee for the American Medical Women’s Association—don’t know what made me say yes. And the ad hoc Search Committee for the Director for Practice Affairs of the American Academy of Otolaryngology/Head and Neck Surgery. We made our short list for interviews, created a list of questions. The conversations on both calls were quite lively. I think by now I wouldn’t be so amazed at how differently different people think.

Two coaching calls with women physician clients. One, an emergency, is going through post-traumatic stress and needs some help with filtering and getting back her confidence—boy do I remember when I was in that phase not too long ago. The other building a great practice and getting help in re-positioning herself. Both are challenging and rewarding as they are doing well.

My emotions went from Death Valley to Mount Everest while getting ready to do my soft launch for Women MD Resources. Trying to finish my free tool kits. Having terrible trouble getting them from Camtasia (a video creation program using my power point) to Screencast and then to my website. Spent hours with tech support and still no go. Then today, I called again and “Parker” figured it out and helped me through. My burden is lifted. I feel liberated. It will get done. We will launch in May. Our next products are in planning, development and production. (And I am hopeful that this weekend at Expert’s Academy will finalize my strategy.)

And then the piece (pee-ess) de resistance. The intro video for my website. One minute and 36 seconds to introduce WMDR with me as the “star.” At the first viewing I fell in love with the producer. Yeah Sarah! My heart soared. I loved it so much. (I hope you will, too.) Funny and edgy and different. I asked them to do something really different. And they did. Way beyond my expectations! Thank you Sarah and Terry at Full Circle studios.

Last Thursday night we stopped in at the Israel Independence Day community dinner and Israeli music and dance. Then on a smaller but no less noisy scale, we enjoyed a Shabbat dinner at our favorite Chabad Rabbi-cum otolaryngology resident-married to a great artist and parents of 5 kids (so far.) A bit of pandemonium peppered with words of Torah wisdom and thoughts about medicine in Buffalo in the 21^st century.

In between we got serious about our big birthday trip, cycling in Italy. Our present to each other. Good thing my Brazilian Butt Lift workout is beginning to show some results, because those cycling shorts are quite closely fitting. Yes, it is true. In my basement. I dance with the crazy Brazilian guy with the weird accent. And I try not to think that my bum bum will never look like those of the very young and svelte women in his studio and on the beach.

Tennis lesson followed by a great match with Dominica. She would have creamed me if not for her bronchitis, but we both had fun. Oh, and let me not forget a really great movie—The Footnote. A must see if you like movies about complex relationships and how they are affected by chance occurrences and serendipity. Very clever, very deep. Hebrew with subtitles.

So as you can see, my life last week has been a pot pourri of ups and downs. Not usually so busy. So now you know why it took a long plane ride to find the time to post. On my way to San Jose for 3 ½ days at Expert’s Academy. Meeting Karen Skoog, my dear friend from Portland, another wannabe “expert.” Keep reading and I will fill you in next week.

From sewing circles to quilting bees, consciousness raising meetings to book clubs, women continue to meet to exchange ideas and support one another in our pursuit of……? When I heard Gloria (Steinem that is) talk about our need to communicate with other women, I was in a roomful of like minded women physicians—we all were devoted to making medicine a better place for the woman physician and women patients.

Having said that, I know that not everyone agreed with the uncompromisingly strong pro-choice stance Steinem makes. But still we all realized that our shared concerns, our shared interests, and in the end, our shared successes (no matter which ones you choose to pursue) were strengthened by sometimes agreeing to disagree while coming together whenever we could, when we agreed.

So back to the more intimate situations when women gather. Take my Busy Women’s Book Club. Sunday night we met for our annual movie and dinner. The best ever vegetarian, kosher, gluten free dinner ever! Fabulous hors d’oeuvres by Karen with potato/carrot/zucchini ? latkes dipped in guacamole and blueberry salsa. Ellen G.’s sweet and sour soup with tofu and fungus (had another more palatable name like elephant ears, I think). Judge Lisa’s greek salad made after a 9 hour drive up from New York that day. Susan made a quinoa salad, always well received. Ellen S. an artful bowl of grilled veggies—loved those brussel sprouts. Vickie with a bean/wild rice/dried sun tomatoes main dish. My contribution—eggplant lasagna (truth be told Sonia made it but I chose the recipe J). And Antoinette took the prize with the most delicious ever flourless chocolate cake with whipped cream for dessert after the movie. We missed Eileen and Stephanie.

Good thing the dinner was great. Rocky sailing after that. Our red-box film, starring Tom Hanks who was upstaged by the new-to-acting kid, Incredibly Close and Extremely Loud, was damaged and couldn’t be fixed. Not with Windex, not with slow forward, not with flipping it. Oh, so disappointing. Definitely gotta see it (and so far it really looked like it shoulda gotten the Best Picture award). Its clever handling of the incredible journey looking for the lock that fit the key was a most fabulous “special effect” I have seen in a very long time.

When we retired for the great dessert and some coffee/tea or more wine, we caught up on our news. Ellen S. is having an exhibit at the Burchfield Penny Art Gallery—a whole floor to herself in Buffalo’s newest museum. Judge Lisa has a new and prestigious position on one of her statewide judges’ committees. Kam Jam is taking off big time nationally but Vickie says she and Mitch are not yet ready to retire. Check it out at Bed, Bath and Beyond!

As for myself, I made a grave error. I shared some personal hopes and dreams. It was on a touchy subject—intermarriage. I must have touched a very raw nerve. The conversation turned a bit ugly. I found myself in the uncomfortable position of trying to defend my feelings about how this would affect my family. In fact, in a place I thought I was safe, with my book circle—now in its 5^th year, I clearly upset someone whom I consider a friend because I shared my hopes and dreams, my concerns and my compromises.

The interchange upset me so much that I couldn’t sleep that night or the next. Now, with a few days gone by, and not too few conversations with others (not in the club), I am more at peace. I know what I need to say (or write because I am somewhat of a coward and I do better on paper) to this person so that she knows my sentiments are those that guide my life, not a comment on what she believes or on how she lives her own.

My friend and colleague, Dr. Jean Shinoda Bolen, has written so much about sacred circles. I have always wanted to be in one. After 5 years of meeting and talking about our feelings through the books we read, I made an assumption that the group was “safe.” Like I always say in my professional life, never assume anything. Better to know. Now I do.

Friday morning session of the Triological Society.  Entry by election with credentials and a thesis.  Still very few women, but growing slowly.

I walk in a bit late, still jet lagged.  The program looks promising, the room less so. I am greeted by a sea of most male heads and dark business suits.  Many bald and even more grey.  An occasional coiffed head dots the landscape with a bright color rarely seen.  By now, I think I should be used to it.  I am not.

The speaker is giving the “Ogura Lecture”–an honor bestowed upon an esteemed member.  Dr. Netterville, from Vanderbilt, did an outstanding job.  Hmm, I wonder, has a women ever given the Ogura Lecture?  And I wonder what Dr. Joe Ogura would think about that?  (I did not know Dr. Ogura personally and never met the man. I have no idea about his gender politics.)  My mind wandered as I looked for a seat to hear the first papers of the morning.

The award winners from this year’s crop of newbie members came up to the podium to present their work.  To a woman (and there were 3), the presentations were exciting and worthy of their distinctions.  I couldn’t believe what I was seeing and hearing.  But there it was–2 women tied for the Mosier award in clinical research, and another woman received the Fowler award for basic science.  Incredible work, incredible odds.

I know that it really shouldn’t matter that the best work of the year came from women.  But it does.  Strong evidence exists that women’s research is judged more harshly than is men’s research.  To have 3 women in a society that is lite on the estrogen and very heavy on the testosterone, is a breakthrough.

Swept up in the moment of hearing novel research, and from younger women colleagues whom I knew, I rushed over to congratulate……and hug, of course. I was so proud of them.

And then the fun was over.  I had a tough time listening to one of my most esteemed colleagues give a paper that had so much valuable data.  Unfortunately, I believe the study design, particularly the statistics, were performed incorrectly.  I think the conclusions were not valid.  During the discussion I stood up and said so.

Although I don’t shy away from discussion (and always love getting comments on my papers), in this case I found it a very difficult thing to do. Public presentation of one’s work is deserving of public discussion. It is hard to publicly disagree with someone’s work, especially someone you like and respect.

Maybe some of you think differently.  If so, why?  And how would have handled it?

I am sure many of you didn’t know that little kids spitting up, or little boys burping, “you know the way little boys do,” or some kids who have a wet barky cough all the time or won’t sleep but an hour at a time for months or years on end or a runny nose non-stop (practically from birth) even with many courses of antibiotics, really have acid and other nasty stomach contents coming up and causing all sorts of these problems. It’s the airway problems, such as refractory asthma or airway narrowing, that can be really worrisome. And these are the airway problems that affect a large portion of the patients whom I treat.

The real challenge is to get the kids to eat the right foods and live a less hectic lifestyle so that they grow up without the acid bathing the esophagus where the cancer rates are rising. Sometimes convincing the parents is the harder task. I am sorry if these facts are alarming, but this is a real concern:

• Esophageal cancer rates are increasing faster than the rates of any other cancer in the world–over 400%.
• Esophageal cancer is occurring more frequently at a younger age (the youngest known case is a 19 year old male).
• Esophageal cancer is highly linked to gastro-esophageal and extra-esophageal reflux disease. These are different problems. GER (gastro-esophageal reflux) goes from the stomach and into the esophagus (swallowing tube). EER (extra-esophageal reflux) goes from the stomach, through the esophagus and up and out into the nose, sinuses, voice box, windpipe mouth and throat and sometimes into the lungs.
• The effects of medications are not fully known so dietary therapy and life style changes are essential components of treatment.

My advice is to teach your children to eat well and to take care of their tummies and the rest of their bodies. But there are some kids who, even with excellent diets and good eating habits, will continue to reflux. Talk to your primary care physician. Sometimes a specialist needs to get involved.

Most importantly, if your doctor tells you that your kid needs to eat differently, lose weight or change some activities, please, please listen. It might bring on more than a few tears now, but later on it might save his or her life.

I hope you found this helpful. At least I feel better now.

Last Saturday night the legendary Gloria Steinem spoke to 300 plus women physicians and medical students at the gala dinner of the 97th Annual Meeting of the American Medical Women’s Association. She spoke about the serious plight of one of the world’s biggest businesses, the slave trade and human trafficking in women and children. At once sobering, and then again a wake up call. There is more to do. Women in the comfortable US need to be ever vigilant in bringing forward not only an awareness of the world wide horrors promulgated against women, but also the promotion of a basic paradigm shift in the way women are treated in all arenas. We cannot afford to disenfranchise, subjugate or waste the talents of half the population of the world.

With her formal presentation over, I quickly jumped to the mike. “Gloria,” I said, “how do we bring the message to the upcoming generations? How would you, a woman of the media, campaign the medical students and educate them on the fact that gender issues are (unfortunately) relevant to them?” And she answered, “You are doing it right here, right now. Keep talking. Keep up the conversation.”

And so I do. At the risk of repeating myself over and over.

The coincidence of equal pay day with an historical visit from Ms. Steinem on our 97th annual meeting of the American Medical Women’s Association should not go unnoticed. While it would seem that these two “injustices” (pay gaps and human trafficking) are disproportionate in their seriousness, I hope you will come to agree with me that their importance is equally worthy of serious attention and quite related.

On April 16, we are once again reminded that women who work outside the home have to work 3 1/2 months longer than their male counterparts to make the same annual salary. Surprised? I hope not. Are you as tired of hearing about this as am I? I hope so.

No matter that we are armed with data, the will to change, and a legal system designed to redress the wrongs we all might face. Data no longer persuades–we have become jaded. The will to change is eclipsed by everyday life. And our legal system is badly broken.

We have made so little progress on the single most important issue I believe women face–equal pay for equal work. It is definable and yet not correctable.  I place no value on the symbolism of Prez Obama signing the Lily Ledbetter Fair Pay Act as his first official bill to sign in his presidency.  Yes, it restored the horrendous mistake of the Supreme Court, but the Prez and the democratic house and senate could not pass the next step, the Paycheck Fairness Act.

Yes, I have come to believe that money is the most important issue. Devaluation has deep and insidious negative effects. Without financial resources to live our lives the way we want, we will always be unnecessarily dependent on a man to eat, clothe and house ourselves and the children we bear. AND, we won’t have the extra disposable income to affect change on the political or social scenes–no matter your political persuasion.

Women physicians continue to be paid significantly less than their male counterparts coming out of residency even controlling for specialty, hours worked, geographic locale, and dozens other possible explanatory factors. Why???? We devalue ourselves more than any other professional group. Why???? Because we are much more sensitive to the competing roles we have: service to humankind vs. our rights to be paid well for our highly developed skills,lifelong commitment to further our knowledge for patient benefit, and our availability day or night for the needs of others.

So even our most highly trained professionals, women physicians, cannot manage to close this stubborn pay gap. So we struggle to fund the grants, the programs, the rescue missions for women enslaved, and many, many other worthy causes. Don’t let this day go by without doing something substantive to improve the lives of women (or a single woman) in any way you think appropriate. Even if it is just passing along this “conversation” to your friends on face book so they can agree or not. Thanks.

The program began with a history of the organization, delivered by past president Eliza Chin, MD, and is detailed in a previous post.  Setting the stage of our legacy and our destiny was inspirational.

My roles?  Here goes.

Co-chair of the Gender Equity Task Force.  I needed to present our quandary to the BOD.  We were awarded a grant, but the funding was inadequate.  What can we do?  As we flew back and forth between meetings and strategy sessions out of the box ideas grew and might save the day.

Judge for the student and resident poster session.  We had 50 poster submissions!  All four of those I judged were absolutely fantastic.  The work was substantive, the questions asked important, and the poise of the presenters undeniable.  Fun and informative and, believe it or not, all four were within my clinical experiences from esophageal myotomies to the width of cleft palates and its effect on speech development.

Participant in the scientific session.  Seven one hour sessions.  Not a clunker among them.  Here are some highlights:

• Marcia Shew, MD on Human papilloma virus vaccine–safety, effectiveness, and myth busting (such as having a vaccine against a possibly deadly sexually transmitted virus will result in greater sexual activity in young women.)
• Lila Nachtigall, MD on the swinging pendulum on the safety and effectiveness of Hormone Replacement Therapy in women.   She tore apart the now 10 year old recommendations from the Women’s Health Initiative with an depth and persuasive counterargument.  So much so that I am going to revisit this therapy for myself.  I hesitate to give you even the headlines b/c I might not give the whole story correctly.
• Carolyn Meltzer, MD chair of radiology at Emory University shared with us incredibly exciting advances in imaging.   The highlight of the conference was a 3-D mammogram that rotated, eliminating shadows and really pinpointed the lesion.  Giving us a taste for her own interest in photography was a special treat.  Check out her website–you won’t be disappointed.
• Randolph Nesse, MD kept us awake and glued to our seats at 3 pm after a very short break.  (This was a marathon day.) “Medicine without Evolution is like Engineering Without Physics” took us way out of the box about our beliefs about how our body works.  He convinced us that certain “illnesses” are have evolved to keep us healthy.  Very counter-intuitive and another one I cannot do justice with any further detail.

The highlight was our special guest evening talk by NY Times best seller author, Rachel Naomi Remen, MD from UCSF (Dana’s medical school in San Francisco).  She echoed my beliefs that we must change the way we see ourselves (and value ourselves–my addition), so we might see what we might become.  And she does this using stories, beautiful stories.  She told us, “Being a doctor is a cosmology, it’s a world view.”  She went on to talk about how the present approach to medical care is about fixing a broken body, a broken world–the embodiment of the male principle.  She challenged us to do what women do–evoke the hidden, make it real and believe in the things you cannot always see.  My take on it:  evidence based medicine can only take the healer so far if she wants to care for and care about people who are suffering and in need of help.

And then I tumbled into bed.  My racing mind and burning thoughts for once extinguished by deeply satisfied fatigue.