The Dishwasher Dilemma

With our old dishwasher, we never knew whether the dishes in the washer had been cleaned. Before putting the dishes in the washer, we had to scrub them well, otherwise, they’d come out almost as dirty as they had been when we put them in. At the same time, the dishwasher would do such a poor job washing the dishes that, even after a cycle, they were never really clean (just ask a few of our guests who often left their glasses of water—or wine!—untouched). So, with the dishwasher full, we never knew whether we should turn it on to clean the dishes or place the dishes in our cupboard.

We finally replaced our old dishwasher with one that’s supposed to be much better and is actually able to do the job it was made to do (eg. wash dishes). Out of habit, we continued scrubbing our dishes prior to loading them on the dishwasher. After a cycle, they’d come out looking crystal-clean. The dilemma was that we didn’t know how little to wash them prior to loading them in the washer. We were afraid that if we didn’t scrub them enough, we’d once again have dirty dishes for dinner.

This is what I call the “dishwasher dilemma:” the hesitation to test the limits of something that is working well enough. For instance, when we were potty-training our daughter, it was difficult to decide when she was ready to go out without diapers. For the most part, she was fine wearing underwear in our apartment, as we would frequently place her on the toilet. However, could we take her to the supermarket without diapers? Could we send her to school without diapers? How much could we push her before she (literally) peed in her pants?

The dishwasher dilemma showed up in my clinic as well. I inherited several patients with lupus and rheumatoid arthritis who have been taking small doses of steroids for years. One of my mentors taught me to always ask them: “What happens when your steroids are lowered?” The wrong answer is: “I’ve never tried.” These patients were doing well on their current treatment regimen and they (or more likely, their doctors) didn’t want to risk a disease flare by lowering the medications. While I understand this, it’s also important to realize that chronic steroids have a myriad of side effects, and as such, it’s important to find the lowest possible dose that still maintains the disease under control (or else to switch to another drug, if available).

In pediatrics, about half of the patients with juvenile arthritis outgrow their disease, but it’s almost impossible to know on which half a specific child will fall. When I see a patient with juvenile arthritis who is in remission, the only way to know whether they are “cured” is to stop their medications and see what happens. Some families are excited about this prospect, as they fear the long-term side effects of our drugs (which, for the most part, are safe as long as they’re monitored carefully, and certainly safer than allowing the disease to go untreated). For other families, the possibility of stopping medications generates fear and anxiety, as they do not want their child’s disease to recur. In general, I encourage most of my patients with juvenile arthritis who are in remission to try a medication wean, the challenge is on deicing when this should occur.

Pushing the limits allows you to see where the boundaries lie…it’s the only way to grow. For our dishwasher, we learned we no longer have to scrub our dishes or utensils (except those with peanut butter on them) since the dishwasher does a pretty good job cleaning them on its own. Our daughter no longer wears diapers during the day (she only wears them to sleep). For my patients on chronic steroids, we were able to wean a few of them to lower doses, thereby decreasing the long-term risks of steroids. For the children with juvenile arthritis, were able to stop medications in a few of them,  while in others their disease flared and they had to go back on medications. But at least we tried.

It is interesting to see that many of the challenges we face in our daily lives are also mirrored, in a smaller way, in our patient encounters. I wonder whether we approach them both in a similar manner.