The headaches started when Mariah Martinez was 10 years old. It was 2003, and she was living in Dearborn, Michigan, with her mother and two sisters. Whenever a headache struck, she would want to put her head down, stay in the dark, and be alone.

Martinez saw her primary-care physician, who referred her to Yasser Awaad, a pediatric neurologist at a hospital that was then known as Oakwood Healthcare. Right away, Martinez told me, Awaad ordered an electroencephalogram, or EEG, a test that uses electrodes to detect abnormal electrical activity in the brain. In a small room, Martinez was wrapped in bandages and had wires placed all over her head. The procedure required her to be sleep-deprived; she came in on one or two hours of sleep after staying up much of the night watching TV.

After performing two EEGs a week apart, Awaad, according to court documents, told Martinez’s mother that her daughter had what are called atypical partial absence seizures. Rather than full-body convulsions, absence seizures are those in which a person stares off into space, blinks, or makes small, repetitive motions. Martinez was confused by the diagnosis; she didn’t know what epilepsy was. Awaad, she said, told her that headaches or staring spells could be signs she was having a seizure, or had just had one. So each time she caught herself daydreaming, she thought, Oh my God, I had a seizure!

Awaad put Martinez on the anti-seizure medication Lamictal. Several months later, her headaches had gotten even worse, and Awaad increased her dose, court documents say. Over the next four years, Martinez underwent 10 more EEGs under the care of Awaad. He told her that most of them were abnormal. Eventually, Martinez was taking a high dose of 400 milligrams of Lamictal daily. The medication made her tired and withdrawn, to the point where she didn’t feel like herself. But she continued taking it, thinking it was good for her health.

Several doctors surrounding Awaad also spoke out against him. In 2002, a developmental pediatrician named Susan Youngs, who worked with Awaad, sounded an alarm. Youngs was contractually obligated to refer patients to Awaad, McKeen said, but she demanded an alternative referral source. “I was concerned that he was diagnosing kids with seizures who didn’t have them,” she testified in her deposition. Later, two doctors spoke up about Awaad misdiagnosing kids with epilepsy in a department meeting. Even then, the hospital, McKeen said, did not launch an investigation.

Woodruff, Martinez’s second doctor, said in court that he had treated a half-dozen patients whom Awaad had “labeled as having seizures,” and that he “never found a single patient” who had epilepsy. He said Awaad’s EEGs were repeated more often than other doctors would typically repeat EEGs.

For his part, Awaad told the jurors that he did not know “where those numbers” in his contract came from—in other words, why they appeared to show that he would financially benefit from performing more EEGs. He said he increased Martinez’s Lamictal dose because she was growing. He denied misdiagnosing Martinez intentionally, and said he gave her the best care he could.


Cases like Awaad’s are especially fraught because differing diagnoses of the same patient are common in health care; it’s where the term second opinion comes from. Often, the only way a misdiagnosis is discovered is if a patient has another specialist check a doctor’s work. Even then, it’s not always clear whether a wrong diagnosis was intentional or not. As Louis Saccoccio, the head of the National Health Care Anti-Fraud Association, put it to me, “People rely so much on physicians’ professionalism that when that trust is violated, it’s a tough thing to catch.”

McKeen, Martinez’s lawyer, told me that Awaad’s case was the first instance of fraud involving epilepsy he’d seen. But just in recent years, several American doctors have been charged with performing various types of unnecessary medical procedures. A small snapshot: In 2013, nearly 400 people sued a hospital and doctor in London, Kentucky, for needlessly performing heart procedures to “unjustly enrich themselves,” as the Courier-Journal in Louisville reported. Last year, a Texas doctor was accused of “falsely diagnosing patients with various degenerative diseases including rheumatoid arthritis,” according to CNN. And a different Kentucky doctor was sentenced to 60 months in federal prison for, among other things, implanting medically unnecessary stents in his patients.

Saccoccio told me that while it’s hard to determine how common the intentional-misdiagnosis style of fraud is, the more typical variety is called “upcoding”: doing a cheaper procedure but billing for a more expensive one. (Awaad is accused of doing this, as well.) U.S. government audits suggest that about 10 percent of all Medicare claims are not accurate, though Malcolm Sparrow, a Harvard professor of public management, told me that’s likely an underestimate. He added that it’s not possible to know how many of these inaccuracies are false diagnoses, rather than other kinds of errors.

Sparrow speculated that doctors cheat the system because “they believe they won’t get caught, and mostly they don’t get caught.” There’s also the fact that doctors often do know more than their patients about various diseases. Sometimes, fraudulent doctors lord that knowledge over patients who get suspicious. In 2015, Farid Fata was sentenced to 45 years in prison for administering unnecessary chemotherapy to 553 patients. “Several times when I had researched and questioned his treatment, he asked if I had fellowshipped at Sloan Kettering like he had,” one of his patients, Michelle Mannarino, told Healthcare Finance.

Some lawyers argue that many of the doctors who get swept up in these kinds of cases are doing honest work: These doctors simply have a different opinion than another doctor who is later asked to review their diagnoses. Writing in The Wall Street Journal last year, the lawyers Kyle Clark and Andrew George pointed out that a decade ago, most health-care fraud centered on something the doctor failed to do, such as neglecting to treat a patient who was actually sick. Now prosecutors are bringing more and more so-called medical-necessity cases, which focus on a test or procedure doctors did do that they shouldn’t have. “Doctors can, and do, honestly disagree by wide margins,” Clark and George wrote. “Show two doctors the same image, and you may get wildly varying—yet highly confident—opinions of what it shows.”

The most devious doctors, who will harm their patients to line their pockets, make headlines. But in a way, even honest doctors are incentivized to err on the side of excessive care. Most doctors work on a fee-for-service basis, meaning the more they bill insurance plans, the more they earn. Some states and hospitals are trying to avoid this situation by experimenting with paying doctors a fixed amount. But that, Sparrow said, creates the opposite problem: It means doctors are incentivized to do less. Ideally, in his view, there wouldn’t be incentives either way. “I don’t want a doctor who is richer for treating me more or richer for treating me less,” he said. “I want a doctor who is on a salary.”

Whether or not Awaad was seeking to enrich himself, he might be parting with his earnings soon. A jury recently decided that he owes Martinez $2.8 million—though this amount will likely be reduced because it exceeds Michigan’s cap on damages. Awaad’s hospital, Oakwood Healthcare, merged with Beaumont Health after the lawsuit was filed, and Beaumont plans to appeal. In an emailed statement, a Beaumont spokesman told me, “While we respect the jury’s recent verdict, we disagree with the outcome and will appeal. We cannot comment about the specifics of this case or others because of pending legal proceedings and patient privacy laws, but we believe patients were treated appropriately.”

Today, Martinez is 26, and she is no longer on Lamictal; Woodruff weaned her off of it. Though she still has chronic migraines, for reasons that aren’t totally clear, she said she doesn’t trust the medical system much. She goes to the doctor only if she really has to. The court’s decision, she said, “was definitely a relief.” It was the kind of relief Awaad had failed to provide.

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On Saturday, I walked a mile from my Brooklyn apartment to a farmers’ market with a clarity of purpose that felt ordained by the heavens. I didn’t really have time for the errand, or a solid idea of how I would use its spoils, but I was compelled onto the sidewalk for a very specific task. It’s tomato season, and I was a woman in want of tomatoes.

I don’t know when tomatoes became an object of such obsession for me, but they seem to have grown similarly important to nearly everyone I know. Tomatoes are in season every summer, but this year the internet has turned tomato season into Tomato Season. Both food media and regular people have latched onto the idea with a fervor that feels more wild-eyed and ubiquitous than in previous years. I hiked to the farmers’ market on a hot, busy day because friends on Instagram and Twitter had posted so many photos of its impossible bounty—the straw that broke the camel’s back, after two weeks of watching them share recipes for tomato sandwiches and panzanellas and tomato-ricotta tarts.

By this month’s standards, a celebration of late-summer produce is an uncharacteristically gentle development online. On the same morning I decided I couldn’t go on living without enough tomatoes to last me the week, news broke that Jeffrey Epstein, the sex offender awaiting trial on charges of sex trafficking, had died by apparent suicide in jail, setting off a Rube Goldberg machine of conspiracy theories about who might be responsible. That news piled on top of a summer in which thousands of migrant children have been held in unsanitary, overcrowded conditions at detention centers at the southern U.S. border and dozens of Americans have been murdered in a rash of mass shootings.

When I got home from my tomato expedition, I read a tweet from the comedian Sarah Lazarus that made me feel like someone had put a camera inside my apartment. “Every day we have to wake up, confront the most upsetting shit we’ve ever seen, and then walk around obeying laws and saying ‘it’s tomato season,’” she wrote. On social media, the grotesque and silly all get swept together in one endless stream, dizzying and outrageous. Chernobyl selfies get uploaded next to pics from last week’s beach day. Tomatoes—wholesome, unextravagant, and endlessly photogenic—exist somewhere in the comforting middle, a mundane joy in an absurd world.

Maybe this tomato season has turned into Tomato Season because everything else can seem so intolerable, or because it’s so inextricably tied to a few particular weeks in an era when the passage of time can seem so unmoored from the human experience of it. The United States is knee-deep in an acrimonious presidential campaign that still contains two dozen participants, and it won’t be resolved until more than a year from now. White-supremacist violence is on the rise, and the technology companies whose products have helped disseminate the ideology seem ill-equipped or disinclined to stop it.

Tomatoes are proof that the world still works in some capacity, at least for now. They still grow. Markets sell them. A tomato with a slick of mayonnaise on soft white bread won’t solve anything, but for the next few weeks, it will taste great. Of course it will. It’s tomato season.

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Dupilumab (Dupixent (R)) is the first biologic available to treat atopic dermatitis (AD). Its effectiveness and safety were demonstrated in clinical trials.

This real-life French multicenter retrospective cohort study included 241 patients treated during March 2017-April 2018.

The median follow-up time was 4 months (still a very short time, considering that most patients are expected to be on the therapy for longer than 6 months).

Conjunctivitis

Conjunctivitis was reported in 40% patients vs 8-13% in trials, a 4-fold increase. Conjunctivitis was treated with artificial tears and cyclosporine eye drops.

Eosinophilia

The proportion with eosinophilia (greater than 500 cells/mm3) during follow-up was higher than that at baseline. The previous clinical trials showed transient eosinophilia in less than 2% of patients, the incidence was 5-fold higher in this trial (9.5%).

27 of 241 patients stopped dupilumab because of adverse events (AEs).

This real-life study demonstrated a similar dupilumab effectiveness as that seen in clinical trials, but it also revealed a much higher frequency of conjunctivitis and eosinophilia.

Atopic dermatitis maintenance (click to enlarge the image).

References:

Effectiveness and safety of dupilumab for the treatment of atopic dermatitis in a real-life French multicenter adult cohort. J Am Acad Dermatol. 2019 Jul;81(1):143-151. doi: 10.1016/j.jaad.2019.02.053. Epub 2019 Feb 27.
https://www.ncbi.nlm.nih.gov/pubmed/30825533

Dupilumab in the Real World: Beware Adverse Effects. Medscape.
https://www.medscape.com/viewarticle/916710

Meghan King Edmonds Compares Parenting in Real Life Vs. Instagram | PEOPLE.com

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Girl quietly playing alone.

Photo illustration by Slate. Photo by Getty Images Plus.

Care and Feeding is Slate’s parenting advice column. Have a question for Care and Feeding? Email [email protected] or post it in the Slate Parenting Facebook group.

Dear Care and Feeding,

I can’t seem to stop obsessing over my 8-year-old daughter’s abysmal social life. I realize that this has more to do with me than her, and I am working on addressing my anxiety, but that will not help my daughter.

To give you a sense of her, she’s funny, sweet, passionate, silly. She can also be a bit imperious (she likes to be right), easily embarrassed (so it’s hard for her to put herself out there and she can shut down pretty quickly), and is learning more slowly than she should about not invading others’ personal spaces (I think she tries approximating intimacy by sitting close to other kids or putting her arm around them and doesn’t seem to notice when they do not like it). Around other kids she tries starting conversations by announcing loudly something like “We saw The Lion King yesterday” and then either repeats it until someone comments or she’ll take their silence as complete rejection, gives up, and walks off to solitude.

She’s told me that she wishes she were “cool” and points out girls in her grade who have this ineffable quality. As far as I can see, the main difference between my daughter and these girls is that these girls aren’t obviously needy and desperate for friends; they have a confidence that my daughter never has had, and I’m not sure why. We sign her up for activities, but there’s only one little girl who ever contacts us for play dates. And the last time she came over, they seemed to have a hard time coming up with things to do. I found this girl riding my daughter’s bike while my kid sat on the lawn reading a book.

She’s very excited that she’s old enough now to attend our library’s after-school game days with her friends, but when she said this, all I could think was: What friends? I am already envisioning my heart breaking while watching kids avoid her while she quietly sets up Monopoly or something. She’s is in a smaller public school system, and I am afraid she’s going to get pigeonholed as a weirdo. How can I help her make friends?

—My Daughter, the Wallflower

Dear MDtW,

No parent wants to see their kid fall down, get hurt, or fail in any way. But every parent will, inevitably, see precisely that.

There’s certainly stuff you can do to facilitate her social life: model social interaction for her, support her in joining teams or clubs, help schedule play dates and that kind of thing. But what you can’t do—no matter how much you want to—is get too involved when a play date ends up with one kid reading and the other riding a bike.

Your kid wants to be cool—everyone does!—but does she feel uncool? She seems more optimistic than you do about her chances of making friends or making inroads toward “cool.” So I worry about your skepticism over things like what will happen at game day at the local library. Maybe she’ll be ignored and feel sad about that; maybe she’ll be ignored and feel fine about that; maybe she’ll make a friend and have fun; maybe she’ll play with some new kid and not have fun. But you can’t manage any of that for her. What you can do is help her process these feelings, whether those are happiness, sadness, or indifference.

Your daughter might be pigeonholed as a weirdo; your daughter might indeed be a weirdo. She may find a friend nonetheless, or it may take a few years for her to find her people. It’s also possible—and my hunch—that you’re overreacting. There are quite a few steps between Queen Bee and complete outcast, and your daughter may be comfortable where she is, even if you’re not. Stay focused on your actual task as a parent (to be loving and supportive and help mold a good person), which is the same whether your kid is Miss Popularity or not.

Dear Care and Feeding,

True or false: Home rules are also rules everywhere else?

Our issue is “no jumping on furniture.” This has been a rule since my daughter could jump on furniture. Grandma says that it isn’t a rule in her house. I think it should be, particularly because it’s a safety issue, and also because it’s disrespectful to jump on other people’s furniture. I’m not walking around denying my child fun at every turn, I promise.

—Rules Are Rules?

Dear Rules Are Rules,

I love your deceptively simple question.

What’s best? To concede to grandmother’s laxity as a demonstration of respect, or to stand firm because that’s the only way to get kids to follow rules in the first place?

Being a parent is a bit like being a dictator: You determine arbitrary laws, you enforce them, and then sometimes you don’t, and eventually your kids realize that your power is just a matter of their perception. Maybe this is your first glimmer of your own inevitable obsolescence: You say no jumping on the furniture, Grandma says no big deal, and your kid learns only that rules are mostly meaningless.

Of course you don’t do all this to deny your child fun; you do it to mold them into your ideal of a good person. One who doesn’t jump on furniture, or chew with her mouth open, or scream instead of communicating, or burp at the dinner table, or pee in her pants.

I think you have to decide how important this rule is to you. If Grandma said, yes, brush your teeth with frosting, or put vodka in your Cheerios, or watch HBO for seven hours straight, that might require a reckoning. I think you’ll still be able to live with yourself if you tell your kid, “OK, furniture jumping is fine at Grandma’s but nowhere else.” As for whether home rules apply in the world at large—I think the answer is maddeningly vague: Sometimes they do, and sometimes they don’t.

• If you missed Wednesday’s Care and Feeding column, read it here.

• Discuss this column in the Slate Parenting Facebook group!

Dear Care and Feeding,

I’m a new mom. Sort of.

I found out I was pregnant two months into a new relationship. After appropriately losing our minds, my significant other (who was extremely supportive) and I decided to place our child for adoption. We also decided to keep this a secret from all but one member of our families.

We went through with a private adoption where we picked the parents, and I saw it all as the best-case scenario given the circumstances. It was, and will most likely remain, the most difficult and devastating experience of my life.

All we’re left with is—now what? The father and I are still together. We are committed to our relationship while also committed to giving each other space to heal individually so that we don’t become only bonded by this experience.

Again, most of my friends and family don’t even know that I was pregnant, and friends who know understandably don’t know what to do or say. I’m hoping you might know of some online or community support resources that I don’t know how to look for.

I see a therapist, but would love to try connecting with other birth parents. It’s an experience that’s so stigmatized and personal, I guess, that there seems to be no visibility, no space for people like me, and it’s contributing to me losing my mind.

—Unmoored

Dear Unmoored,

Thank you for writing. I’m glad you’re seeing a therapist, though it’s clear what you need is a human connection to a specific peer group. I would first reach out to the social workers or attorneys who facilitated your adoption placement for recommendations on local groups or organizations. There are a handful on social media, too—make a fake account on Facebook (against the rules, sure, but protect your privacy) and poke around for terms like birth mother and see if you can find one that feels right to you. If neither of those is helpful, I would call an adoption agency in the nearest urban area and ask one of the social workers there for their recommendations.

While my advice is pretty basic, I wanted to write back to you because I’m a parent by adoption. So maybe it’ll be somewhat helpful (to me, possibly, more than you) for me to say: You are a mom, no “sort of” about it. You made an incredibly difficult choice, one that you should see as an act of parental love. It’s important to acknowledge that this choice was devastating. Let yourself continue to say that—not as a way to sink into despair but as a way to confront it frankly. The gratitude of the family you helped make will not help you heal, but I hope it’s something you can hold onto nonetheless.

Your desire to heal as an individual speaks to your levelheaded approach to your relationship. But I don’t think you and your partner should feel you cannot discuss this at all. Perhaps it would be beneficial for you to see a therapist together; perhaps you already do.

You have your own reasons for keeping this from your family; maybe over time you will be able to be honest with a relative who might be supportive. You generously defend your friends whom you have told. If you have a friend whose response has disappointed you, perhaps you should tell them, “Hey, I need to talk about this, and I just need you to listen, because you’re my friend and that’s your job.”

I hope you’re able to unburden yourself with another mother who’s gone through what you have via one of the paths I recommended above. I think you will have complex feelings about this for the rest of your life. But I do not think you will always feel like you are losing your mind. I hope that even writing this letter offered some kind of catharsis, and that hearing this response will be some kind of comfort. I’m rooting for you, and the child that you carried, and I’m sure that the family you helped make are as well. Good luck.

Dear Care and Feeding,

What is the etiquette for dealing with strangers who criticize your parenting when your kids actually aren’t behaving very well?

I was in a cafe with my sister-in-law and our kids (my 6- and 4-year-old boys and my 3-year-old niece). After the kids finished eating, they got a little rambunctious. The 4-year-old grabbed a toy from his brother and ran off, resulting in a predictably loud reaction, and the 3-year-old started trotting back and forth to the garbage can from our table with napkins and such. As my sister-in-law and I were settling them down, an older woman marched over and started lecturing us on the kids’ behavior.

Her opening line was “I raised two kids who are a lawyer and a therapist,” to which I answered, “Good for you,” hoping she would catch the sarcasm and think better of the rest of what she was about to say. No such luck. She went on to ask, “Why are you letting them treat this place like a day care?” and so on. When my sister-in-law tried to politely point out that we were correcting the loud voices and running, she snapped, “Well, they keep doing it. That is just unacceptable.” We didn’t say anything else, and she ran out of steam and left. We laughed it off (wondering out loud if future lawyers never run around in public!), but now I think we could have handled it differently.

No question this woman was out of line. But I can’t deny that the kids were rowdy (although I didn’t think it was that horrendous, and we were in the process of addressing the issue when she approached us).

I don’t want to be one of those moms who let their kids run wild in public. Should I have apologized for their behavior? Should we have left immediately?

Should I have pointed out that while I myself have an advanced degree, I do not choose to measure the success of my parenting by my kids’ eventual professional attainments (or by their current impulsivity, for that matter)? Is there a good rule of thumb for these kinds of situations?

—Mother of (Sometimes Naughty) Dragons

Dear Mo(SN)D,

When someone violates etiquette, as this intruding stranger did, we sometimes feel more pressure to adhere to it. A blanket response that I like is “Thank you for your opinion,” with as much sarcasm as you like, though that’s a nuance lost on the kind of crazy old coot who reprimands strangers’ small children by pointing out that her own children were, decades ago, well-behaved.

Sure, your kids were rowdy. Even the most darling children sometimes are. You don’t want to be a mom who lets her kids run wild in public, but that doesn’t mean they won’t, sometimes, run wild in public. You can apologize for their naughtiness, though you’re probably more inclined to when strangers aren’t being jerks to you. It’s probably best to focus on what you can control (your kids’ behavior) than what you can’t (adult stranger’s behavior).

—Rumaan

More Care and Feeding

My son, who just turned 5, has a friend from his previous school, who just turned 4. She’s cute, but demanding, spoiled, and hard to have around. She’s also completely obsessed with my son. It’s gotten to be too much to handle, and I’m ready to cut ties. Can I do that?

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