A Spoonful of Sugar

Recently, we've been having some medical issues with my almost 3 year-old daughter, Lyra. Over the last month, she's been hoarse with a couple of episodes of wheezing. After bringing her to the doctor, she's been preliminarily diagnosed with asthma.

Can you picture what it must have looked like? There I am with my little daughter, trying to do a nebulizer treatment while she fights to escape my clutches. It's amazing how strong and wiggly a little girl can be. Dealing with my daughter's medical issues has me thinking about how to make the difficult aspects of medicine palatable.

I'll give you a concrete example from my daughter's story. At the beginning of her first nebulizer treatment, the medical assistant tried to put the mask over my daughter's face with the headband to hold it on.

My daughter was having none o' that! She tore the thing off and took a deep breath, as if to say, "Here I go daddy. I'm going to scream until your ears explode!" And my daughter can SCREAM.

Just before the ear-shattering cries arrived, my pea-sized brain started working…just in time. First, I put the mask to my face to demonstrate it wouldn't hurt. Then – and here's where my parenting skills really started working – I said, "Look, Lyra, I'm breathing clouds!"

Well, now she wanted to breath the clouds too (my daughter wants to be involved in everything). I held the mask just a little away from her face while she breathed the nebulized medication. The doctor in me knew that it didn't matter if the mask was completely sealed to her face, since she would get the medication blow by. The father in me was just happy she wasn't crying!

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The next step in the process was getting her to take oral medication. Before starting my daughter on steroids, we're trying Singulair^®. Lyra doesn't swallow pills, so she was prescribed a chewable tablet. Our parental creativity told us to crush up the pill and mix it with chocolate ice cream (she LOVES ice cream).

So far we've been successful, because we stuck with Mary Poppins' famous advice: "a spoonful of sugar makes the medicine go down." Whether you apply this literally (put some sweet into the medicine to make it taste better) or figuratively (couch the bad things that happen within something positive), it's good advice.

In podiatry, one of the saddest topics we have to discuss with patients is the need for an amputation (thankfully more common than discussions about terminal cancer). For me, I try to use Dr. Poppins' method during these counseling sessions. For example, when I start this discussion, I usually avoid the term "amputation," at least at the beginning. I might say something like, "Mr. Patient we're going to have to remove your toes." In my experience the word "amputation" typically has the same affect as the word "cancer", with patients instantaneously thinking the worst. Euphemisms can be very helpful. I then go on to discuss, say, a transmetatarsal amputation, relating the high success rate of TMAs and how this may avoid a more proximal amputation. We discuss that Mr. Patient will still have the rest of his extremity and will still be able to walk with appropriate shoes. As our discussion progresses, I slowly and deliberately become more blunt about what will happen during the procedure and potential complications, eventually getting to the "amputation" word. Of course, my consent actually uses the word "amputation." However, by the time the patient gets to signing the consent document and sees the actual procedure – a very concrete statement – he is mentally better prepared. The "medicine" goes down much easier with this spoonful of sugar.

There are so many little spoonfuls of sugar we can use in life to make the necessarily negative things easier to tolerate. My ever-clever residency director taught me about the Oreo cookie method of criticism. If you have to provide feedback, start with something positive/complementary, proceed to the actual criticism, and end on a positive comment. In this way, we build up those we criticize rather than break them down – truly constructive criticism.

Whether it's dealing with sick children, sick patients, or anyone else, making the unpalatable in life a little easier is a good rule of thumb. Listen to Dr. Poppins and use that spoonful of sugar liberally. It'll simply be your job to figure out if that's a teaspoon, soupspoon, or a shovel!

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]