The Necessity of Compassion and Empathy to Heal Devastating Childhood Illnesses
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Dr. Mumper: Well, Sid, thank you, and you are one of my main mentors so I have learned so much from you and just hearing you say that…I’m starting to tear up a little bit. But I was trained as a pediatrician, you know, I did my pediatrics residency and chief residency in University of Virginia, and I was recruited to go to Central Virginia. I worked in a large group practice for about five years, and it was just not the right fit for me. Because we were having to see lots and lots of patients a day, and I always felt like I was backing out of the door just as the parent was getting to the real reason for the visit. So I went and worked in a residency program for 11 years as Director of Pediatric Education which I actually loved and teaching Medicine is my biggest passion, I think, and it really inspires me and it’s always wonderful to keep learning new things. My dad was a college professor and I clearly remember dinner times where we would talk about history and the events of the world and such…so, I think he instilled that vision in me that I had to always be learning new things to stay fresh. But about 1995…1996, I started noticing that the kids I’ve been taking care of at that point for 15 years started looking different and there were more and more kids that had neurodevelopmental problems and, at the time, I very naively thought, ‘well somebody should really check into this’, and came up with one of those ‘well, why not me’ moments and the more I looked into it, the more convinced I was that something bad was happening that probably contained a real lesson for the planet and humanity. So, long story short, I tried to work out a way to incorporate that into my current job. That didn't really work. So I did what seemed — at the time to my husband — to be an insane thing, which was to leave a salary job with benefits and open a solo practice. And that was in the year 2000. So I did that, and very shortly after I met Mary Megson who is another pioneer in this field, and went to her office in Richmond, spent two days with her and was just blown away by the way that she thought about medicine was very different from what I had been taught to do. And I was recruited by a number of patients to try to help their kids who had complex problems. And so I started a practice called “Advocates for Children” and eventually I expanded that to “Advocates for Families”, and a few years after that I started the Rimland Center which is in honor of our good, dear friend, Bernie Rimland, who was extraordinary in his vision. I can clearly remember sitting at the swimming pool in the year 2000, reading Bernie’s book that was published in the mid-1960’s, and having the idea that he was just a prophet — he was such an incredible visionary. So long story short, I started the Rimland Center in his honor and I have gotten to mentor clinicians — not as many as I would like — because these were people with practices and lives and who have to travel, but it’s just very rewarding to learn from them and then share with them what I’ve had the privilege to learn through all our think-tanks and conferences. So one of the things I look forward to every year is getting together with my “tribe”. I have a couple of my tribes now: one is the group that’s the Institute of Functional Medicine, and I have now gone through all the modules in that training and hope to sit for the exam in April; and then my tribe that grew out of the experience at ARI, where we have think-tanks and exchange ideas and do conferences. So I feel that it’s been such an honor, and privilege and blessing for me to get involved in this. I got to travel, to many different countries to meet clinicians there and lecture. I love doing that because I love expanding my horizons. So it’s all been good!
Dr. Baker: I come from an academic family myself and around the dinner table I would hear conversations that sometimes raise the question of whether so and so should give up his or her job that has been already now 10 years as headmaster, or something…time to move on, because if you stay in it for too long then things get kind of rusty. With that in mind, after I have been 10 years in the job of coordinating some of the aspects of the Autism Research Institute’s program that became called the DAN! movement, it was time for me to shed my uniform as, say, an organizer of some of the educational things, and of course you took over for me and it was a joy to have you come along and make it so much better…so…
Dr. Mumper: Well I wouldn't say that. You had very, very big shoes to fill and it was very intimidating for me when I started. But the fact that you had faith in me meant a lot.
Dr. Baker: Well, the faith has been justified. The mention of Bernie and his book, I think is something the viewers of this interview should really take to heart. That book was an amazing piece of work. He wrote it, of course, at a time when he was sort of a nobody…
Dr. Mumper: Oh yeah.
Dr. Baker: A recent PhD…and just a young fellow. And he scrutinized the literature on autism very, very carefully and cleverly. In the book he had an index of people who he had cited in the book. So if you open the book and you’re some sort of expert, you wanna hear, ‘here’s this new book on autism, did they say what I know?’, ‘did they mention me?’…that kind of thing. And so he appealed to the egos, of course, of all the people who had…from whom he had gathered his information.
Dr. Mumper: Right, right.
Dr. Baker: But also as a lovely, subtle effort to present all the things that put together his strong and persuasive argument that the way that people viewed autism at that time was completely off-track, and he put us on track. So we agree and share a wonderful experience of having been taught by Bernie.
Dr. Mumper: Can I just add, Sid, that one of the things the viewers may not remember is that Bernie really debunked the myth of the “refrigerator mother” — this was such a destructive concept in psychiatry and the old view of autism was that some of the mothers were cold and uncaring, which is the polar opposite of what my experience has been. And I just wanna share one anecdote about a family I worked with in Italy and there they were still working under the old model and this wonderful Italian mother who was so full of love, and affection, and nurturing for her child had been going to “psychotherapy” for four times a week for like a couple of years, and the focus of the psychotherapy was ‘why she hated her son and made him autistic’. I could not believe that that was happening and she told me, I think it was 2006, so I just thank God for Bernie for helping that myth die.
Dr. Baker: It was a very big rock to move.
Dr. Mumper: Yeah.
Dr. Baker: It was so embedded in the thinking that I was trained in it in Yale where my professors all hung on to that whole view and I have met, in my life treating families going back into the 1970’s, families that were really destroyed because the doctor who did the first interview about this child’s problem, which was usually a guy, and would turn to the father and say, ‘well you know, the problem here is Sally, she’s the one who created this problem’, and for more than a generation, two generations, this myth — this poisonous myth — would go through that, you know, ‘grammy, once she becomes the grammy of this family, ‘she was the one who had all this started, because she was somehow mentally disturbed.’ Really just a most evil…and I would say cowardly approach to reality on the part of our profession. So Bernie was able to turn that around. And that was a tough one because it was so embedded in the culture, and of course that…it went from there to genetics…
Dr. Mumper: Right!
Dr. Baker: So it’s not your mother’s fault, it’s your grandmother’s fault…
Dr. Mumper: Right.
Dr. Baker: And now we’re struggling getting that stone moved. But we agree in that that legacy comes from Bernie’s book which everyone should read…
Dr. Mumper: Yeah.
Dr. Baker: It’s so beautifully structured to make sure he wasn't gonna get too much of a backlash from people…it’s very subtle the way he got it in, but eventually he said sort of the idea that children got this way is really ridiculous and…so let’s think about what the data shows.
Dr. Mumper: And it’s the 50th anniversary of that book this past 2 years, so…
Dr. Baker: Yeah, yeah.
Dr. Mumper: Everyone should remember that milestone too.
Dr. Baker: Exactly. Well, we…both of us have learned a lot from our patients and most of what I learned as a doctor I think I ultimately learned from stories of my patients. So maybe you could tell us a couple of stories from your patients that helped you get to where we are now today.
Dr. Mumper: So one of the first patient’s stories that really affected me was a little boy that Mary Megson took care of. And he was a child that, at the age of 4, was seen by a local university and diagnosed with 3 or 4 things including ADHD and oppositional defiant behavior, and I have a very striking photo of him with his face grimaced and his hands like this, and he was pushing on his head and it just looked to me like the kid was in pain. And he had been tested at the university proclaimed to be in the mentally retarded range and the parents were prepared for the fact that they were gonna have to institutionalize him. And the mother found Mary Megson. Mary did a number of things to work on his gut…Long story short, he had severe gut inflammation and lo and behold, when she fixed his gut — or the family fixed his gut — he was a different child. And later on the testing it turned out that he had an IQ of a hundred and fifty. And now he’s in his mid-twenties, a very bright guy, and it just was such a striking lesson to me for a couple of things: one is there are limitations to the testing. And I really try to shy away from closing any doors for any kid because I don't wanna create a self-fulfilling prophecy or a situation where the family gives up hope. And the second thing was the extraordinary power of the human body to adapt to all kinds of circumstances given the right tools. And, unfortunately, in the environment we are now, we’re doing many, many things to our bodies that are trying to hijack this extraordinary machinery that keeps us healthy and thriving. And it was just very inspiring to see the whole trajectory of this child’s life totally changed in a period of about a year.
Dr. Baker: Yeah.
Dr. Mumper: So that was one of the first. Shortly after that, I met another patient who was 16, and he was nonverbal but very bright and he came to my practice when I was really practising in a very small basement part of an office that had 3 little rooms and my receptionist was always tripping over my office manager. But the family sought me out and this kid who couldn't talk, you know, the first time I met him I said, ‘can you tell me what you would like if I, as your doctor, could do something that would really help you, what would be the main thing you wanted?’ And he typed very clearly without any spelling errors, ‘I would really love to talk like the other kids.’ And that was such a good lesson to me ‘cause I realized that these kids are so much in there and it gave me so much incredible empathy to think about what it must be like to have all these thoughts and feelings and not to be able to tell your parents or your friends. It’s just extraordinary the way these kids have to cope every single day of their lives. So, a few things about this patient…the bottom line is it’s now 10 years later and he still doesn't talk. So not everything here works out the way we would hope. The good news is, when I met him he had an erosive esophagitis, literally an endoscopy, he had a whole in his esophagus from the acid in his stomach and he was leaking stomach acid into his chest cavity, so he was in constant pain. He had bad inflammatory bowel disease, and would have a lot of self-abusive behaviors which we know are often associated with some kind of undiagnosed pain. So, the good news is, I was able to collaborate with a GI guy in Roanoke which is close to me, who did an endoscopy on him, and after a pretty rocky post-surgical course that involved a lot of infections because he has a very dysregulated immune system, he basically is not in chronic pain. So, even though I feel like a failure — because I can't give him what he most wanted — the parents are actually very grateful that he’s not in chronic pain, so I have to take that as a partial victory. And he’s one of my kids that’s such a yeast kid, which I attribute all my knowledge about how important that can be to treat to you. I actually maintain him on 2 systemic antifungals and a bunch of other natural things like Saccharomyces Boulardii and have been doing it for years. Monitoring his blood counts because of the very rare possibility that he might have a depletion in his white count and elevation in his liver enzymes and he never has, so I think that some of the things we were taught to be kind of afraid of — like systemic antifungals because of horrible side effects — you know, if you really think about the patient as an individual and follow them as an individual, you’d figure out if that patient is the one in “x” that’s gonna have that problem. So he’s happier and healthier now and I keep trying to learn what might help him do this very, very complex neurologic and muscular process that we call speech. It’s really a wonder that any of us can talk…
Dr. Baker: Yes.
Dr. Mumper: …when you think about how incredibly complicated it is.
Dr. Baker: Talking and swallowing…
Dr. Mumper: Yeah.
Dr. Baker: …are these things that the tongue does that is such a problem for people with injury to their reptilian brain which controls this function that we take for granted when we can do it and, boy, it’s a tough one when you can't, but it’s amazing to see how it can be restored in some kids who get the right treatment which is usually, as you just said, in the gut. I have a boy like that from whom I learned this, and he was told by the Yale Child Studies Center — which is pretty high ‘up there’ in terms of authority — and this was well into years into the 90’s when telling that children should be hospitalized for the rest of their life is not fashionable anymore. But his parents said, ‘well, you know, he’s in such bad shape, it would be better for the other child in the family to have him institutionalized because he’s not gonna go anywhere. And after antifungal treatment, we ended up…Lamisil was the choice…he blossomed. Every time we stopped the Lamisil he would just completely lose it within a few days get it right back again. The people at school didn't know what the story was because this child changed from going like this [*pointing down*] to going like this [*pointing up*]. And after a few years of that he came off the Lamisil and he turned out to be a very high-IQ chess champion and an extraordinarily gifted artist. He was strong in two fields. And this was a boy was going to be institutionalized because the authority said he was a loser. And it’s hard to walk away from stories like that without becoming pretty zealous about those kinds of approaches that we share. I’m convinced that our dear colleague, Dan Rossignol, is on the right track with helping us learn about so-called evidence-based studies that validate things, but stories is where I started, and I still depend on stories to learn the things that we know.
Dr. Mumper: One of the things I’ve been disappointed about is that, in sharing patients with other clinicians, I don't get very many calls that say, ‘wow, you know, little Johnny looks so bad the last time I saw him and now he’s doing so much better’, you know, ‘can you tell me a little bit about what you did?’ I would love it if that happened.
Dr. Baker: It is extraordinary, I agree. Sort of in another area, I have my patient who was seen by a doctor in New York who kinda wrote the book on her disease. And it was a disease that is generally considered not something that will go away, and hers went away completely with a very simple treatment along the lines we were talking about, this is an inflammatory joint problem. And she went back to see the doctor and he was so angry and dismissive about the treatment that we had done, he said, ‘you might as well have rubbed peanut butter in your hair, for all this treatment could have helped!’ But of course it did help. And here she was, completely cured of something that was supposed to be incurable! It was his thing, you would think that he would at least sort of open his eye a little bit to say, ‘well maybe there’s something I don't know’, but he was the big expert so…
Dr. Mumper: Well, the thing that I’ve always loved about you is that you’re so curious about everything. And everytime I see you you’ve got some new project and I think that most people, when they go to medical school, have a lot of curiosity and have a lot of desire to learn. But something happens in the process and I don't exactly understand that. But I really think that it’s vital, for anyone thinking about diving into this pool with us, to maintain their curiosity and to be in awe of how complex everything is. And I think that, as people age, they need to get more and more and more humble, and sometimes it goes in the other direction.
Dr. Baker: I couldn't agree more. Another thing about family, our tribe, that has developed since our first meeting in Dallas in 1995 when Bernie and Jon Pangborn and I put together this effort to find common ground, and scientists and parents and practitioners were all in the same room, about 30 of us, and we checked our egos at the door, and tried to find things that we agreed upon. It was really extraordinary because there were a lot of people with very different skills, and interests, and practices that were sort of out of bounds for other people in the room…
Dr. Mumper: Right.
Dr. Baker: …but we tried to find things we agreed on. But the scientists among us were really very forgiving that way, because they were open-minded and they listened to the stories and tried to figure it out and we came to a picture, a diagram really, that I made of how we thought things put together, it stands up pretty well to this day…
Dr. Mumper: I agree.
Dr. Baker: And in some ways, we…the plot was…in retrospect now, was to go out into unexplored territory and set traps where we could catch scientists who would help us find a way and into our tribe came new scientists from whom we’ve learned so much and I’ve been really touched by their participation and the way that they’ve brought to light some of the fundamentals of this landscape that we’re in. And so my question is, which among them you remember particularly as sort of bringing new ideas and new ways of looking and new findings to us?
Dr. Mumper: You know, the first thought I have is actually of a clinician-scientist, Anju Usman. I very clearly remember at a think-tank many years ago, it must have been in the mid-2000’s, sitting across from her and she talked about the Pfeiffer approach, about Zinc and Copper balance, and metallothionein, and a lot of very intense nutritional biochemistry. And that was something that was pretty new to me because I think my nutrition in my medical school was maybe 2 hours. And I was schooled in, you know, “prescription pad medicine”: make a diagnosis and give the treatment for it. So that was a real eye-opener for me. I also clearly remember William Parker who did this extraordinary presentation about the gut microbiome and immune dysregulation, and how many, many chronic diseases — from autism to inflammatory bowel disease, to many chronic degenerative diseases of the nervous system as we age — have a lot of common ground in immune dysregulation. And he built upon the work of the hygiene hypothesis and took it much further and went into the idea about how human society now in developed countries doesn't have the benefit of helminths that we coexisted with for so many years. One of my other extraordinary scientists that is also such a wonderful person is Bob Naviaux. Bob is very well schooled in genetics and mitochondrial disease and does these extraordinary experiments on ocean water in San Diego to look back in history from an evolutionary biology standpoint which is just extraordinary and totally boggles my mind. But I had a very simplified idea about what mitochondria did, remembering that they are the “powerhouses” of the cell but he opened my eyes to how there are so many more functions, and specifically in relationship to how mitochondria communicate with other cells. And along the way here…there’s just…with all these lessons we learn, we learn that cells — which we have trillions of — have all these organelles, which sometimes thousands inside them, and they communicate and talk with each other with chemistry, and it’s just so mind-boggling but it’s so fun to learn about it. I was also really impressed with Welch’s work on oxytocin. You know, she looked at NICU’s in…that were premature…babies who were premature and in the NICU — Neonatal Intensive Care Unit — and did a lot of work on initial stress and oxytocin levels. And oxytocin — which, as you know, is the hormone that makes humans bond and makes mothers get up in the middle of the night to breastfeed their babies when they cry — has been one of the valuable clinical tools for me because I use it a lot for kids that have trouble with peer relationships, have trouble recognizing facial expressions so they can't tell if their friends are getting annoyed with them, or they’re happy to see them, or if their friends wanna play a different game. And so…especially in those kids that are…sort of 5 to 9 or 10 year old age range, where their peer relationships must be so confusing if they can't read the other child’s facial expressions or emotions. The oxytocin can be such an extraordinary gift to them and their families. So those are just a few of the extraordinary people that I've gotten to meet.
Dr. Baker: Well, we’re privileged to have had such wonderful people join our tribe, but two that stand out in my mind, of course, are Richard Deth…
Dr. Mumper: Of course.
Dr. Baker: …who is such a great teacher and such a person who has insight into the biochemistry of behavior that explains it so well…
Dr. Mumper: Yes.
Dr. Baker: And Jill James, of course, came along right after that because Jon Pangborn have found Richard and got him involved and it was really a moment there like he was lecturing in Philadelphia when he realized that he was in this tribe, it was listening to him because he hadn’t experienced that before and he became quite emotional on the podium and I wasn't sure what was going on with him, and now years later, I learned it was because he was having this moment of just feeling overwhelmed by the fact that we were all listening to him and understanding and benefitting from all the gifts he had to give us.
Dr. Mumper: Yeah, I remember that very well, it was very touching.
Dr. Baker: What a moment that was. And then, of course, he was the one who said, ‘well, you know, the person you should get on board is Jill James, and I’ll help you get her’. ‘I’ll help you get her’, and she of course has been an enormous gift to our tribe.
Dr. Mumper: So I’d love to tell a story about how I used the work of Jill James and Richard Deth and what they taught me to change the life of a little boy that came to me. The parents brought him when he was about 4 and he had lost language and was cowering in the corner and acting with these so-called “autistic behaviors” that the parents were very distressed about. And I was on a steep learning curve at that point, but I just kinda started diving in and I worked on his gut first and then I worked on his immune system, and then I started pretty much playing around with his methylation biochemistry. I will say that I…for all the people out there who are trying to learn this for the first time, I listened to Jill James who explains it in an extraordinary way about 3 times before it all really clicked for me. And long story short, this child ended up being a really good responder, so in a period of about eleven months, with the various things we did — and I pretty much did everything anybody had talked about at that point with him, including treating yeast and really working on his immune system and his gut, using a lot of my traditional tools also, you know, Singulair, for example, because of his allergies. But he very rapidly changed back into the kid that the parents initially knew. And by the time he went to kindergarten he could name all the planets in the Solar System and he’s able to recite the Pledge of Allegiance at school. And the parents, you know, are so grateful and I remember one of the really rewarding things…I save all the notes that parents give me. Because if I’m having a rough day, it’s nice to pull that out and use it as a little thruster boost to keep going through the rest of the day. But the dad was in a company in a pretty high level, traveled a lot for work, flew a lot…And one time on a plane he wrote me an email and talked about how he was crying on the plane because he realized that he had his son back, and expressing appreciation and…that was so extraordinary and much more rewarding to me to do something very complicated that had a really big payoff in the end than the kind of just day-to-day, bread-and-butter pediatrics. For me, you know, where I’m treating ear infections and colds and that sort of thing, and I still do that because I do…I’m really wrapped up in the prevention aspect now so I have used my General Pediatrics practice as a little bit of a laboratory to try to apply the lessons of what I've learned from the children and the families in the autism spectrum to try to save the next generation, at least my little portion of the next generation. And so it’s all been good, yeah.
Dr. Baker: I wouldn't…I wouldn't say ‘little bit’ in reference to your work that combines the skills you have and the experience you have in the regular pediatric practice with this other side of the question because you have discovered and documented a major change in the prevalence of autism in your own community, in your own practice, that is utterly persuasive in terms of the preventive measures that can be taken with respect to risk for autism spectrum problems and other things that we find within this wonderful metaphor we have of a ‘spectrum’ that goes off in all different directions.
Dr. Mumper: Yes.
Dr. Baker: Can you say a little bit about your experience with coming up with these basic changes that families should consider in going on to build a family that has fewer autistic children than they might have otherwise, given the prevalence in the community at large?
Dr. Mumper: Well, I think that the history is always crucial. And one of the simple changes that I've made is to pay very careful attention to the story when the mother had antibiotics during pregnancy, or recurring yeast infections during pregnancy, or when the baby had to have antibiotics for some reason early on, like they had transient respiratory distress and the physicians were concerned about sepsis and gave ampicillin and gentamicin or the one-third of women who were colonized with group B strep and often get IV antibiotics during delivery, which was a public health decision made many years ago: weighing the risk benefit of missing a child with horrible group B strep which can be fatal, versus giving antibiotics to the rest of the world that doesn't get it. So when I see any of those factors, I really try to talk about probiotics to be started early in life, like 2 weeks or a month. And I have a very, very high rate of breastfeeding in my practice — much higher than in the surrounding community — because I devote time into supporting that and when the parents breastfeed, or the mothers breastfeed…it is actually a team sport because the dad has to be there too…but the breastmilk contains a lot of the good bifidobacterium, lactobacillus, that will populate the gut but I feel good about going even further than that and using a multi-strain infant probiotic that will create diversity in the gut. There’s a lot of emerging evidence about the microbiome that shows that the diversity…the degree of diversity in our gut — especially in the first year of life — is absolutely crucial to set the stage for whether you’re going to have a life with or without chronic illness. So that’s one simple thing. The other thing, ironically that I left out of my paper, was what I do with vitamin D. I don't know if you have this experience but anytime I write anything, as soon as I turn it in I hate a lot about it and I know I left out something important so…John Cannell, who was a great disciple and scholar about vitamin D wrote to me after my paper came out and said, ‘what about vitamin D, Elizabeth?!’ ‘Oh yeah, I do that!’ So I start kids on vitamin D at either the two-week or the one-month visit, depending on whether they’re coping with other things and try to really maintain that throughout the year. We live in Virginia which is too far north for our children to get enough vitamin D and when I looked at my children with autism I had many vitamin D’s that were in the 15 to 17 range and I've come to appreciate the role of vitamin D — not just for bones — but for the extraordinary role it plays on the immune system as a very good modulator of good immunity, but also the role it has on the hippocampus which is very important for memory and learning. So that’s one of the things that I do. I also actively campaign against using acetaminophen with vaccinations. The classic teaching has often been that acetaminophen is pretty benign and we know that if you overdose on it you get horrible liver problems. But people in this country use it very liberally and I wish I had a nickel for every family that called me after hours and said, ‘my child has a low grade fever and I’ve already given them acetaminophen.’ I just think we have to understand that fever is part of our response to a foreign antigen and not to overreact to low grade fevers. So with every well baby visit that I do, where I give vaccines, and I do give vaccines on a modified schedule, I literally handwrite on a page where I’ve already have a handout, to use ibuprofen as needed instead of acetaminophen, but to just use a tepid bath first. I mean, you know, go back to basics — it works, evaporation works, you know, that’s why nature does it. So I do not use much acetaminophen in my practice. Other things include trying to get an early sense of whether a child is immune dysregulated and use really early clues. Like one of my favorite early clues are skin rashes and eczema. Many people who are in a very busy practice, when confronted with eczema may do something like telling the parent to use a steroid cream. And I presented a case yesterday when we were talking about a little boy from Australia had been on a steroid cream everyday of his life for his eczema for like 4 years, and now when I see eczema I always think what is this trying to tell me about the state of the child’s immune system? And I’m always surprised at the number of kids who have 5 or 6 or 10 ear infections and get 5 or 6 or 10 courses of antibiotics and no one ever checks quantitative immunoglobulin A, for example, which is a very important part of the immune system to work on both the gut and respiratory infections. I actually had one child that had over a hundred courses of antibiotics and never had his QIG’s done — Quantitative Immunoglobulins — I just don't really understand that, I think that people just are so rushed that it’s hard to slow down enough to really think about what’s going on. And I'm very, very worried about this trend toward clinical pathways and protocols where these protocols are designed that if your patient comes in with the diagnosis of asthma, this is the checklist that you use. It just seems to take a lot of the thinking out of the process about the patient as an individual. So, those are some of my strategies, and I think over time, I hope over time, people will think about doing it. I think that the system conspires against that because of the way the reimbursements are done. And as of early October, we are going to a new classification system for diagnoses, ICD-10 which I think has a hundred forty thousand diagnoses that we are supposed to pick from. And it’s primarily for insurance encoding reasons, and I think it’s gonna be a huge waste of my time and it may do me in, in terms of trying to work within that system. So I worry that the other pediatricians and family physicians in this country are going to waste more time on that and have even less time for thinking about the individual patient. We’ll see.
Dr. Baker: You and I have been in conversations with practitioners now for a number of years who are attracted to some of the ideas that we’ve just been talking about, but are terrified of stepping out of the circle where they found a certain amount of comfort because of its familiarity, while at the same time being anxious that it’s not really covering bases that they really feel in their hearts and minds they should be paying attention to. Stepping out of that circle is scary and my exit from the circle, many, many years ago now, but I remember that it felt kind of strange to go out on my own kind of do this thing and I’m…your story is similar but so now that we’ve done it I think you have some wise words to say to practitioners who are thinking about stepping outside the circle a little bit and thinking about chronic illness in a new way.
Dr. Mumper: Well, first I’ll tell you a funny story. My husband, as you know, is a psychiatrist, and when I first started talking about ‘this is horrible, there’s this epidemic, and nobody is paying attention, and if we only did this it would all be better!’ He got worried about me and he actually sent me to a psychiatrist to make sure that I wasn't manic. And I probably did sound a little manic when I think back about it, but I got checked out okay. I just really believed that you need to do what you love and do what you think is right. That is not always a very practical thing and I had people, like yourself, that gave me practical advice about how much it would cost, and how bad my overhead would be, and whatever I thought my budget was, to triple it. All those people were right and I necessarily do all that but I've still ended up, you know, 15 years later without any regrets because I've had such a rich experience in terms of emotional and intellectual curiosity, not, frankly, in terms of money ‘cause I am relatively poorly paid compared to every…not relatively — very poorly paid — because I still work within the insurance network for a lot of my patients, compared to other physicians in my area. But they don't go on 4 international trips to lecture every year and I just think that that tradeoff is a good one for me. I would tell the young people starting out — even people who are abandoning their old practice and may not be so young — that if you listen intently to your patient and tell their story back in a way that proves to them that you understood what they said, they will love you for that even if things that you come up with to treat their child don't necessarily work the first time, they give you a lot of credit for trying and listening and thinking and worrying about their child. So that little strategy that I've learned from you, and all the folks at IFM, is just extraordinary. The other thing that I always try to do before I walk into a room, and this is very hard but I always try to take just a few seconds to forget about all the emails that I haven't answered and all the prescriptions and paperwork for speech therapy and physical therapy that I have to authorize, and just try to center myself, focus on that child and that family. And I try to always walk into the room…even if I'm not feeling it…looking at the child first and being very excited to see them and finding something to compliment them about. It can be a little thing, it has to be a sincere thing, but I always try to start out with them realizing they’re the focus of the conversation. And then I always try to be very careful about what I say in front of the child, and usually what I do for a new consult for ADHD or a behavior problem is to say something like this to the child, ‘your mom and I are gonna be talking about some pretty boring stuff so what I thought we might do is just do the fun part first, I’ll do your checkup and none of it will hurt and then you can go out watch some videos or play on your iPad or play on my train table.’ And they usually take me up on that, and that way I can talk about the child in a way he doesn't hear all the things that the teachers and the parents think are wrong with him. So I think that’s really crucial. Sometimes people think that when kids can't talk they don't understand. And I just always try to be very careful about what I say in front of them. And whenever I mention a problem, I always try to sandwich it with some good stuff about the child. And you taught me that. You, of many people, have taught me that. So those would be some of the philosophical things I would tell to people starting out. And the other thing is not to sweat the small stuff. You know, there’s so many things that can drag us down and when you look at it. at the end of the day…I cleaned out my files over the Labor Day weekend and found all these correspondence about all these problems over the years that I’ve done all these calculations on…and now I can barely remember them. And so don't get sucked down by all that stuff.
Dr. Baker: But I certainly endorse what you’re saying about complimenting children. As you know, I have a swing outside my office and my patients, the first that they do is get on the swing and it’s on a 50-foot rope so they can get a pretty good ride on it, and start out very sort of uncertain about it and then I get to see the smile come and the joy come from really having almost a chance to visit a nearby planet on this swing…
Dr. Mumper: Yeah.
Dr. Baker: …and then I get to be able to say, ‘boy, you were so good on the swing, you’re a great swinger’, and so they hear something positive from me and set the stage for and emphasis on abilities and not getting all tied up on disabilities as the only subject of conversation and that’s I think something that parents and children appreciate a lot. Understanding that our focus on disabilities sometimes makes them worse. And strengths are what leverages healing so, I try to emphasize those, so we agree on that point. How about the practicalities in your office of trying to run a practice that is still in sort of routine…so-called routine pediatric — nothing that’s really routine, but that kind of thing, and at staff are just crucial to the way that your patients will perceive your practice. It’s too confusing to do it the way that I do it, but we have all…I do have a nurse practitioner now who’s wonderful and she doesn't do the autism piece but she can help me absorb some of the acute pediatric illness that walks in the door. The kid that needs to be seen that half day but I’m in the room with a child who really needs an hour and a half of my time. So I try to have Mondays and Thursdays be my sort of “intense autism days”, and the other days of the week the more general pediatrics. But here’s the thing: my general pediatrics practice…word got out pretty quickly, so whenever I get a new patient it’s usually not just a healthy kid, it’s a kid who has ADHD, or a kid who has multiple allergies, or a kid who has some kind of chronic GI problem. And one thing I've had to learn to do in that situation…and it’s hard for me, because I wanna learn the whole story, you know, at the beginning so I can start putting it together, but because those people are still in a traditional insurance-based model, I have to make myself say, ‘okay, this is your visit to establish care, I’m gonna get all the background information, but if you really want to delve into what’s going on with the GI problems or the ADHD, or the allergies, we need to set aside another visit for that.’ The clinicians out there will know that what is rewarded in medicine now is multiple short visits and the average pediatric visit in this country now is about 7 minutes. And I cannot even begin to imagine how anyone does that in 7 minutes. I don't have any block in my office that’s less than 15 minutes and I can't do anything in 15 minutes so I usually run over through my lunch hour and all that. But my patients are…I try to not to get more than about 15 minutes to half-hour behind, but when I am behind and I apologize for it most people forgive me because they realize that if they wanted to talk I won't cut them off. So it’s a tradeoff and its…I have not liked being on-call all the time, except when I’m out of the country, for 15 years. That has not been good. And I think that maybe one reason that neither one of my kids wanted to go into medicine at all! But, anyway, it works for me and my staff and it’s a challenge, but then, you know, challenges keep me younger than I would be otherwise.
Dr. Baker: Well, thank you for sharing your story with the viewers and it’s been a great experience for me to be able to have this conversation with such a dear friend as you’ve become.
Dr. Mumper: Well, Sid, if you have not given me the incredible honor of being the medical director for ARI after you left, none of the wonderful things that have happened to me would have happened so you changed my life trajectory!
Dr. Baker: Okay, that’s a deal![/text_block]
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About Elizabeth Mumper, MD, FAAP
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[op_liveeditor_element data-style=”e30=”][text_block style=”style_1.png” align=”left”]Dr. Mumper is President and CEO of The RIMLAND Center. Dr. Mumper graduated magna cum laude from Bridgewater College with a degree in General Science. She attended the Medical College of Virginia, did residency training at the University of Massachusetts and University of Virginia, and was invited to serve as Chief Resident of Pediatrics at UVA. She spent over a decade as Director of Pediatric Education at the Lynchburg Family Practice Residency Program and maintained a clinical faculty appointment at the University of Virginia for 16 years. She served as Medical Director of the Autism Research Institute for five years.
Connect with Dr. Mumper
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