Likelihood Ratio

Likelihood Ratio is a topical blog that Dr. Hill has created, bringing common sense and wit together about current state of Media & Pediatrics. Continuing from the roots of his book “Dad to Dad”, Dr. Hill writes from the unique perspective of Doctor/Dad to help readers navigate the sometimes murky and confusing waters of being a caregiver for a child.

I really wouldn’t be doing my job as a parent if I hadn’t downloaded Pokémon Go and started racing my kids around town to various PokéStops. It helps that I have a patient and indulgent wife, who complains only a little after being left in a running car in the middle of a strip mall parking lot while I follow my phone into a drainage ditch. 

I’m as excited as anyone that a mobile video game finally has kids staring endlessly at their phones…outdoors! An obvious next step would be for developers at Nintendo and Niantic to add a few new creatures to the Pokédex that appeal to, um, more senior players like me. I’m offering the following ideas for free:

  • Charminder (12 combat points). This adorable little guy is a Fire creature with the power to make sure you move those steaks from the grill flame to the infrared zone before they burn. His evolved form, Charmaster (26 combat points) can baste ribs for up to three hours. He is most vulnerable to the memory-diminishing attack of the Beerbasaur (6, 12, or 24 combat points).
  • Gyrtle (32 combat points). A creature from the Water weight environment, this Pokémon dwells discretely under the trainer’s clothing, where it makes unsightly bulges invisible. Given enough candy it evolves into a Spanx (260 combat points) with enhanced compression powers. Warning to would-be trainers: if you eat the candy yourself, your Gyrtle may explode.
  • Ivylauyer (520 combat points). Really by far the most important Pokémon to have in any battle, this fearsome Grass/Poison creature hurls powerful Soots, Injunkshuns, and Moshuns, for enough stardust or candy, payable in advance. In the unlikely event that your Ivylauyer appears to be losing a battle, it can offer the attacker a Seddlement, saving you precious points. The evolved form, the Pardnersaur (1000 combat points), benefits from the victories of its allies and gains candy even when its trainer loses.
  • Peakedachu (27 combat points). This worn-looking Pokémon saw his best days during high school, or maybe that one semester he played baseball in college. Looking at him gives the trainer a certain satisfaction that while he seemed pretty intimidating back then, he’s really downright average now, so how do you like them apples? His evolved form, the Hazzbin (3 combat points), can provide the trainer a transient mood boost through its powers of Shoddenfroyd.
Posted: July 17, 2016, 4:58 pm

Don’t you just love it when you hear that you can do anything you want if you try hard enough? I know it’s true, because when I hear people say that, I try really hard not to assault them.

But what about when it’s not true, like when I try to act cool around my teenagers? Or when pediatricians try to convince vaccine-hesitant parents to protect their children from disease? Science has spoken, and it says, “Give up.

And talk about trying! The study’s sponsors, the Group Health Research Institute in Seattle, selected doctors to receive intensive 45-minute training sessions in talking to parents about vaccine hesitancy. They followed these sessions up with written support, monthly emails, and on-call assistance. That’s not just support, it’s college-freshman-with-helicopter-parent support.

And what was the effect of all this communications training? The trained doctors were exactly as incapable as untrained controls of convincing hesitant parents to vaccinate their children. There was some drop-out from the experimental group, as one of the docs left practice to become an FBI hostage negotiator.

So now what do we do? I don’t know about you, but I’m going to take the time I used to use talking about vaccines to improve my Snapchat game. Then my teenagers will definitely think I’m cool.
Posted: June 1, 2015, 7:55 pm

Do you think you can read English? Let’s try a little quiz: which of the following 8th grade human growth and development courses should I sign my son up for if I want to order him an attractive 14K gold promise ring, and which one will show him how to put a condom on a banana?

A) Stepping Stones to Better Living: Responsible Decisions
B) My Life: Choices Today for a Healthy Tomorrow
C) They make promise rings for dudes?
D) Why would a banana ever need to wear a condom?

For the answer, you, like my fellow New Hanover County parents, will have to point your browser to The problem here is that while the names both suggest that responsible decisions are better than decisions that are rash, wanton, ill-considered, random, drunken, or forced on one by a physically or socially dominant partner, only one of these family life programs has a good track record for keeping kids from prematurely developing a family life. Or from contracting any number of diseases ranging from the unpleasant to the terminal. 

Why stop at sexuality education programs that don’t fully educate about sexuality? Why not a driver’s ed class where they just watch traffic and talk about not crashing? Why not a keyboarding elective taught in cursive? I would have appreciated a PE course where we watched replays from the weekend’s games and discussed how we could have improved on the coaches' calls (I hated dressing out).

Don’t get me wrong: I’m all about abstinence, especially where my own precious kids are involved. I’m also a strong proponent of world peace. But not ensuring that my kids get comprehensive and responsible sexuality education? That’s bananas.

Posted: May 20, 2015, 6:03 pm
When you were a kid, did you ever get the sense that the grownups in your life weren’t telling you, like, really important stuff? I think back on so many unanswered questions: “But how does Santa Clause get to all those houses in one night? Why would you ever want to go on vacation without me? Are martinis really the only way that Daddy can eat his olives?”

A new study in the journal Obesity proves that withholding the truth from children may be the key to addressing the childhood weight crisis. According to the authors, a restaurant chain called the Silver Diner (first sign of deception: not a one of their restaurants is made of actual precious metal) launched a new kids’ menu in 2012 that conveniently forgot to make any mention of “french fries,” replacing them with “strawberries” and “mixed vegetables.” It’s not that kids couldn’t order fries, they just had no way to know they were an option unless their parents slipped up and said something, presumably after having a few too many olives.

Here’s the thing: the kids were happy. They ate a measurably healthier diet, and revenues went up at Silver Diner as parents flocked to the chain to enjoy snickering behind their menus as their children snarfed "mixed vegetables." 

As a parent, not only do I wish that we had a Silver Diner around here, but I am just beginning to realize the power we might have if we all bond together in giant conspiracies: “I’m sorry, but Apple will not sell an iPhone to anyone under age 18.” “No, fighting with your brother is not on the menu, but I see here that they have hugging, playing soccer, and reading together.” “There are certain critical vitamins that dads can only obtain through olives. Now go eat your strawberries.”
Posted: May 14, 2015, 2:36 am

In the wake of the Disneyland Measles Epidemic of 2015, many people are calling on one of the epidemic’s chief engineers, “Dr. Bob” Sears, to retract his alarmist rhetoric on vaccines. Here’s my recommendation: back off of Dr. Bob! How is he going to turn this thing around if it looks like he’s just caving to pressure from every reputable doctor and public health advocate in the country? 

This process is like potty training: as long as you keep reminding the child to go, he’ll resist. Instead, we need to stop mentioning it and act like we don’t care if it ever happens. Then, once he can save face, I’m confident that Dr. Bob will find some way to admit that vaccines are safe and measles are dangerous. We can then give him an M&M. In case he needs a head start, I’m offering this script, but he’s welcome to make up his own stuff, as many people feel he has done before:

“There is a lot that we didn’t know when I first wrote The Vaccine Book. At that time, for example, no one had any idea that measles is among the most contagious of all human diseases. We had no clue that it kills between 1 and 3 of every 1000 people it infects and may lead to severe and irreversible brain and nerve damage up to 10 years after the infection. If only today's advanced research tools had been available to doctors working in the 1950’s, or even the 1990’s!

We have also had much more time to gather data on vaccine side effects. When I first wrote my book, I had great hopes that encouraging parents to delay or forego vaccines would lead to a race of super-healthy children to whom the scourge of autism and a bunch of other vague, poorly-conceived “risks” of vaccines would be unknown. As it turns out, these unvaccinated kids contract and spread measles and whooping cough, but otherwise they’re just like vaccinated kids, except that they have at least as high if not a higher rate of autism. Hey, it was worth a try!

Some of my colleagues accuse me of publishing The Vaccine Book because The Baby Book was already taken, and it’s all I could think of. Some say that I was looking for a way to ingratiate myself to celebrities, or at least their nannies and dog walkers, by seeming to offer a unique take on infectious diseases and the nature of the human immune system. To those people I say celebrities’ nannies are actually quite lovely, and you’ll never believe the stories I can’t share because of HIPAA.

But those issues are not important now. Being a scientist means having to say, ‘Oh, there are new, compelling data, and it appears that my theory was wrong.’ I am that scientist. So please, immunize your children completely and on schedule and, until you do, please avoid theme parks, regular parks, parking lots, parkour, Parker Posey, Park Slope, Park Avenue, Park City...pretty much any place another human might breathe in the next two hours. And don’t worry about me; I will remain in the limelight in my new job: warming up audiences for Dr. Paul Offit.”
Posted: February 3, 2015, 2:50 am
Are you as conflicted as I am about all the good news regarding alcohol, cigarette use, and drugs emerging from the world of adolescent health? Parenting four teens, I’m really relieved, but then I fear that we’re going to have to edit some of the classic teen movies for this new, more responsible generation. Here are some screenplays I’m currently working on (private message me for my agent’s contact information):

The Healthy Breakfast Club: A geek, a cool girl, a rebel, a jock, and a stoner learn to transcend stereotypes when they join forces on a Saturday morning to take over the school cafeteria and concoct an all-paleo meal, cleverly evading the eye of their carb-loving principle.

Porky’s, the Vegan Years: A ragtag band of high school boys have you-know-what on their minds - that’s right, shower safety. They sneak into the girls’ locker room and apply non-slip surfaces to the tile, pausing only to caulk up a hole in the wall, thereby reducing the school’s carbon footprint.

American Pie Presents: SAT Prep: Let’s face it, no one ever got into Stanford by going to Band Camp. Five high school friends are determined to gain early admission to highly selective universities before prom night ends. Over the course of this 16-hour film, viewers master the subtleties of English vocabulary and composition as well as advanced algebra. Tickets are $1200 and include the cost of workbooks and pencils. The movie’s most talked-about scene includes one boy being caught baking pies for Meals On Wheels because he has heard the experience would make a great essay topic.

I really hope that at least one of these ideas gets optioned, if only so that my own teenagers can learn to share my love of quality cinema. (Please, someone send this link to Molly Ringwald.)
Posted: December 21, 2014, 2:21 pm
A study from Texas demonstrates that in many cases language barriers are keeping pediatricians from talking to their Hispanic patients about their weight, even when those children are obese. Participant Alberta Jimenez said through an interpreter, “I could tell the doctor was trying to say something, and when I heard the word ‘pesado,’ I got excited, but actually the doctor just thought a pesado was Mexico's official unit of currency.”

In reviewing the 26 video recordings of wellness exams, researchers identified other culturally insensitive language blunders by clinicians. One, in trying to explain how Body Mass Index is calculated, actually said, “Se acepta dolares americanos?” Another, attempting to advise a patient on reducing sugar-sweetened beverage intake, asked for “dos cervezas por favor.” Officials from the Mexican consulate and US Foreign Service continue to work to smooth the resulting tensions.
Posted: November 17, 2014, 6:38 pm

A new study in the Journal of Nutrition Education and Behavior confirms what many parents have come to suspect: nobody really packs a lunch box like the ones people post on Pinterest, no one. Researcher Alisha Farris, a Ph.D. candidate at Virginia Tech University, led a team in evaluating the nutritional value of 560 packed meals for preschoolers and kindergarteners and 750 school lunches straight off of the steam table. Compared even to the lumps of random brown foodstuffs that pass for school lunch in this country, home-packed lunches had more calories, more fat, more saturated fat, more sugar, less protein, less fiber, less calcium, and less vitamin A.

An unnamed research assistant on the study stated, “I don’t know where these Pinterest moms are getting this stuff, probably from stock photos, because after unwrapping the first 250 lunches, I was ready to gag. I did not see a single star fruit face with blueberry eyes, not one pinwheel of turkey and low fat mozzarella wrapped in wheat flatbread, and no goji berries arranged in the shape of an American flag, just acres and acres of bologna and American cheese. Pinterest is, pardon my French, bullshit. That is French, right?”

Future studies will focus on whether the contents of Lunchables have less or much less nutritional value than the polystyrene trays they come in.
Posted: November 11, 2014, 4:12 pm
Detergent manufacturers were swift to respond to an article published in Pediatrics today describing thousands of toxic exposures to young children, most under age 3. Said a spokesperson, “We understand that our laundry pods resemble pacifiers, teething rings, candies, and other things that toddlers are supposed to put in their mouths. We are working closely with those industries to help them re-design their products so that they are less appealing to children. We feel that if candies, teething rings, etc. were to be sold in grays and browns and stored in childproof packaging, kids would quickly learn to distinguish them from our products. We appreciate your support as we work tirelessly to prevent childhood poisonings."
Posted: November 10, 2014, 6:38 pm
A lot of clinicians are confused about the new American Academy of Pediatrics guidelines on treating bronchiolitis, released just in time for the wheezin’ season (see “wheezing” doesn’t really rhyme with “season,” but if you adopt a faux rural accent you can kind of make it work). To help, I’ve translated the technical language of the guidelines into plain English, using words like “wheezin’”. You’re welcome.


1a) Clinicians should definitely diagnose bronchiolitis. That way it looks like we know what we’re doing. This diagnosis should be made by taking a history, examining the child, then standing back and saying, “Looks like bronchiolitis.” Then go on to explain that this is not the same as the “bronchitis” that grandpa just got treated for with Zithromax at urgent care.

1b) Clinicians should get a worried look on their faces if the disease looks bad and say something like, “This looks pretty bad.”

1c) Whatever they do, clinicians should resist the urge to order chest x-rays or labs. You already know it’s bronchiolitis. What, are you going to act all surprised when the result comes back “Suspect bronchiolitis?”. Remember, no matter what you see in comic books, no amount of radiation will give the child superpowers.


2) Once you have diagnosed bronchiolitis, run and get your office’s nebulizer. Take it to the parking lot and dash it to the concrete until it’s irreparably broken. What were you thinking, considering giving that kid albuterol? Now you won’t be tempted.

3) Go back in the office, open your code cart, and find the epinephrine. Look at it sternly and say, “I’m saving you for croup and anaphylaxis.” Close the code cart, and give the key to someone you trust to hide it from you until the patient leaves.

4a) Break into the ED late at night and steal all their hypertonic saline nebs to use for brining turkeys (I recommend a minimum of 3 liters for a 16 lb bird). It does not help bronchiolitis, but if they have it, they’ll use it.

4b) If the child is admitted to the floor, and the hospitalist uses nebulized hypertonic saline, do not be insulting about it. The data are still unclear, and besides, you already have your turkey brine for this Thanksgiving.

5) Do not give steroids to children with bronchiolitis. They will grow unusually large muscles and be elected governor of California, where their unfortunate personal decisions will cloud their legacies.

6a) Don’t bother giving oxygen unless the patient’s oxygen saturation is under 90%. To do otherwise will make you look like a big wimp who’s frightened of a little old O2 monitor.

6b) Don’t use continuous pulse oximetry in the first place. You have eyes and a stethoscope, right? When children are really hypoxic, many of them will take on a bluish tint, like in the movie Avatar.

7) Do not use chest physiotherapy for infants with bronchiolitis. Do you really think that beating a kid like a drum with a cupped hand does something other than provide full employment for respiratory therapists? That said, sometimes the rhythm is pleasing and helps soothe you to sleep.

8) Step away from the antibiotics. Bronchiolitis is a virus, you know that, right? It causes a fever and rales, right? So dude, unless pus is streaming from the ear, why do you want to also invite diarrhea into this picture? 

9) If bronchiolitis is interfering with a child’s hydration, put in an IV or an NG tube and help the kid out. Congratulations, finally you have an intervention! Pat yourself on the back, you did good.


10a) Pavilizumab is a total racket, okay? We don’t care how many lunches the reps brought your staff, if the infant in question was born after 29 weeks gestation and didn’t have chronic lung disease or heart disease, leave it. Expect your local detail person to cry a little, but remember, he’s not thinking about the wellbeing of your patients. He’s remembering a puppy he lost when he was 7.

10b) For infants born before 32 weeks and who have lung and heart disease, go ahead and give the pavilizumab. That detail person has a family to feed.

10c) Give it 5 times in the first year of life. You can’t stand to see your drug rep cry, and he also has a boat payment to make.

11a) If you’ve touched a patient with bronchiolitis, wash your friggin’ hands! You were wearing gloves? So what? Is a little soap gonna kill you? Make sure you wash adequately by singing all of Wagner’s Ring Cycle.

11b) Alcohol hand sanitizer works, too, especially for those who can’t sing in German.

12a) Ask about tobacco smoke exposure when you see a kid with bronchiolitis. If you get a positive answer, gently shake your head from side to side and sigh heavily.

12b) Explain why you are so very disappointed about 12a.

13) Encourage moms to breastfeed exclusively for the first 6 months of an infant’s life by saying, “You wouldn’t want your baby to get bronchiolitis, now would you?” Nothing builds a therapeutic relationship like fear and guilt.

14) When diagnosing bronchiolitis, give parents and caregivers a handout to read. People love handouts, and they meet Meaningful Use guidelines. Make sure you get a new handout that explains why you’re doing nothing about the bronchiolitis. Then, get to the next room quickly. Remember, it’s the wheezin' season!

Posted: November 9, 2014, 2:43 pm

Researchers using sophisticated microphones and computers reported in this month's Pediatrics that dads talk to their infants about 1/3 as much as moms between birth and age 7 months. Reaction from outraged fathers was swift. Dan Rogers of Akron, Ohio, father of 3, said, "Whoa." LaShawn Coleman of Memphis, Tennessee took to Twitter to proclaim, "#Hmmm." Dr. Johann Schlemmer, tenured professor of linguistics and child development at Harvard was quoted opining, "Well..." Clearly this research has opened a floodgate of paternal opinion, and we will continue to follow the debate until the groundswell of conversation finally ebbs.
Posted: November 8, 2014, 11:26 pm
When the editor of Pediatric News asked me to start the Needles blog in 2011, no one had ever succeeded in making pediatrics hilarious on a regular basis. Many of my loyal readers agree that, after 126 Needles columns, they’re still waiting. Now I’m starting “Likelihood Ratio,” where I hope that one of the commenters will finally pull it off.

Those of you with medical or statistical training will recognize a likelihood ratio as that formula you had to write on the palm of your hand right before the test so you wouldn’t flunk. In case you’ve since washed your hands, it’s a calculation that tells you whether the sensitivity and specificity of a test makes it even worth doing or whether the test will just make you and the lab more money while simultaneously giving the appearance that you’re a smart and caring clinician. 

Like “Needles,” this blog will be a place to explore developments in the pediatric literature and to ask ourselves, “Should I even care?”. If all goes well, we’ll laugh together, we’ll learn together, and I’ll get offered lucrative speaking engagements in attractive destinations. Don’t worry, I’ll post photos. Welcome, then, to Likelihood Ratio. I hope you’ll like it.

Posted: November 7, 2014, 2:27 am



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