Saturday, November 3, 2007
Regardless, when our children become sick, it is sometimes hard not to dissect the past 72 hours in an effort to deduce which of our friends' children made little Johnny sick. Sometimes it is simply an innocent fact-finding mission with little malice or misgiving. Other times, however, we rack our brains, pursuing a mini witch hunt, until we have concluded who passed the unfortunate germ to our child.
From a public health standpoint, it is a well researched fact that an average healthy child will come down with 6-8 viral illnesses each year; if the child attends daycare, this number jumps to 8-12 viral episodes. Furthermore, it is also known that children will often shed a virus for several weeks, even after they themselves appear perfectly healthy. Viruses, especially during the winter time, are rather hardy and can survive for several hours on fomite surfaces, including door handles, countertops, grocery carts, toys, and wherever else they happen to slobber, touch, or lick (in other words everywhere!).
Thus, when investigating the possible places or people that a child may have acquired a germ, it really is a total crapshoot. And assigning fault, especially if there is any ill will involved (pun intended!), is a dangerous and inaccurate game to play.
I often counsel my families that they should resign themselves to the fact that their children will become sick multiple times each year, with the bulk of the illnesses occurring during the winter time (the lower humidity and increased tendency for people to remain indoors leads to a greater survivability and sharing of germs). With this in mind, I believe that it is an impractical standard for people to avoid public gatherings when their children have a simple viral illness (or vice-versa, to impose this standard on others). The fact of the matter is, most of the time, whether their "sick appearing" snotty child joins the party or not, there will be plenty of germs abounding regardless.
If we truly want to avoid becoming ill, we would have to essentially live in a bubble. Even the most cautious, Purell-addicted family will encounter their fair share of germs each year. And even if they only socialize with well-appearing children, some of these kids may still be shedding germs from an illness they got over several weeks prior.
A simple but practical set of guidelines I pass on to parents is as follows:
1. Babies under 3 months should avoid contact with sick children. Anyone who plans to physically touch the baby should always wash their hands thoroughly before playing with the child, no matter how healthy they appear.
2. If a child is harboring a significant illness such as chicken pox or scarlet fever, they should be quarantined from other children until they are no longer contagious. For a full list of illnesses that should be quarantined, a pediatrician should be consulted with a quick phone call. The scope of this discussion is too exhaustive for a simple blog.
3. If a child is playing happily but has some mild symptoms (i.e. runny nose, cough, mild non-bloody diarrhea), they should NOT be quarantined and free to attend church, school, birthday parties, political functions, poetry readings, etc.
There are other circumstances that also need more detail; for example, an immunocompromised member lives in the household. However, the above general rules cover most circumstances.
It is this author's opinion that playing the blame game with colds and viral illnesses can not only be inaccurate, but ultimately fruitless. Rather focus on the upside! Your child's immune system has just been battle tested one additional time, and this can only strengthen him in the long run. Perhaps, rather than consigning blame, you should send the offending germ donor a thank you note. And maybe a little Purell.
Wednesday, October 3, 2007
There have been a few times, after listening to a parent's story and examining them, it seems clear that the previous doctor did not accurately diagnose or work-up the patient before me. I use the word "seems" because there are two sides to every story, and were I to ask their doctor his/her take on the matter, my judgment on the matter may sway.
However, more often than not, my overall impression usually does not find fault in the previous doctor; rather, I often assess mentally that the patient's disease(s) has probably evolved from their initial presentation, and had the family followed-up with their primary doctor, the correct diagnosis would have eventually been made.
I need to qualify this blog with a few thoughts:
1. Pediatrics is a different beast than adult medicine. In adults, debilitating diagnoses such as cancer, heart disease, stroke, etc. are more common, hence there is a greater propensity in adult medicine to misdiagnose a life altering ailment.
2. Doctors do make mistakes. This is not an attempt to exonerate myself or all pediatricians from errors. We are all human and every doctor has their share of war stories. Of course, we all try to keep these stories to a minimum.
3. I practice in an area of Houston where, for the most part, my surrounding colleagues are all excellent well-trained physicians, for whom I hold mutual respect. There is excellent camaraderie and perpetual educational conferences where we freely exchange information and medical trends. Thus, when a patient of their's seeks my second opinion, it is rare that I discover an egregious error.
4. Most of the mistakes I have personally witnessed are not from when patients have seen another pediatrician, rather they are seen at follow-up visits after a family has visited a non-pediatric emergency room where the physician on call did not regularly see children. The suburban strip mall after-hour clinics tend to be the most frequent offender. Of course, I have also met and know some excellent doctors in each of these settings. It just tends to be more of a crapshoot.
To fully demonstrate the point of this blog, I will delve for a moment into the minutiae of pediatric medicine. Let's take a look for a moment at the pathophysiology of bacterial pneumonia. Pneumonias can actually be categorized into 3 general groups divided by etiology (cause): bacterial, viral and atypical bacteria. Of these 3 groups, the one that can turn into an ICU nightmare is the bacterial pneumonia. The other 2 etiologies are of less clinical significance and, for the most part, are not dangerous. However, should a bacterial pneumonia not be properly treated, a normally healthy child can suffer significant consequences including the infrequent ICU hospitalization.
So how does a bacterial pneumonia evolve?
1. First, a child will catch the common cold (caused by one of many viruses). This will turn his nose into a faucet, which causes many to suffer from post-nasal drip, where the mucus runs from the back of their nose down their throat and into their lung. This essentially turns their trachea (windpipe) into a water slide, or more specifically, a mucus slide.
2. Second, the water slide of mucus/phlegm will accumulate in a pocket of their lung. Interestingly, the very cough that many parents want to alleviate and squelch, offers the best protection against the formation of these biological cesspools. In effect, cough is protective and beneficial! God is smart!!
3. A bacteria (often being harbored harmlessly in the child's nose) will ride the water slide down from the nose into the lung. Should it find an acceptable domicile of collected mucus, it will set up house and began to multiply. Once a sufficient army of bacteria are formed, the germs will infiltrate the surrounding lung tissue, firmly establishing a pneumonia.
This entire process usually takes 1-2 weeks, however should the offending agent be an aggressive bacteria, the timeline can be significantly shorter. The pathophysiology for ear infections and sinus infections is also very similar. So should a parent bring in a child during the first few days of this timeline, the appropriate diagnosis would be an upper respiratory infection (cold) caused by a virus, and thus the appropriate treatment would be tender loving care and watchful waiting.
As the child evolves from having a cold into a pneumonia, there is usually a clear change in their overall appearance. Often they will appear less energetic, have shallow labored breaths, their appetite/play will decrease, and there may be a second peak of fever. Most mothers will pick up on this and bring them back to their pediatrician for a second check. However, should the mother decide to switch doctors at this point, it may appear that the original doctor who diagnosed a cold made a mistake, when in actuality the disease has evolved since the initial presentation.
Second opinions are certainly warranted in certain situations, especially if you feel that your doctor is not adequately addressing a deteriorating illness. Either a lack of guidance and roadmapping may leave a parent feeling slightly lost and scared, or the doctor may simply be missing the boat on the underlying diagnosis.
However, it is more often the case that your child has simply progressed from their initial presentation, and allowing your own doctor to observe the change in symptoms will often be your safest recourse. Having seen how your child originally presented and then being able to see the change in presentation, will proffer your physician a bird's eye view on the entire history of the illness. Hopefully, you have enough faith in your pediatrician that you trust he has made the correct original diagnosis, and will also make a change in his assessment, should the opportunity necessitate itself. If this faith does not exist, it may be time to find a doctor in whom you can put it!
This blog is not to deter you from seeking second opinions, but rather to help you understand that sometimes a change in clinical diagnosis is not always indicative of a mistake but rather an evolution in the natural history of a disease process. And it may be in your child's best interest to stick with one doctor through thick and thin, especially if you've already found a doctor who you trust.
Monday, September 10, 2007
Veteran reporter John Lawton speaking to the American
Association of Broadcast Journalists, 1995
As a pediatrician, I try to log in a respectable amount of hours in a noble attempt to keep up with the latest research concerning new treatment modalities, changes in immunization guidelines and patterns in endemic outbreaks of particular germs. Not only do I find articles concerning such topics intriguing, I feel an innate sense of duty to my patient population to stay well-informed. After all, parents spend their hard-earned money and valuable time to seek out my advice whenever they have a question that concerns their child.
Overall, the internet has, for the most part, made my job as an educator easier. Many parents log in their due diligence on various topics prior to their visit, maximizing the value of our conversation. Furthermore, the internet acts as an external screening tool for parents wishing to validate the advice they receive from me; generally, the informDation found on the web is quite reliable and I not only condone this, I encourage it. I will often end a patient visit by writing down my presumptive diagnosis and suggest that the parents read more about their child's condition at home in order to fully understand the natural history of what is to transpire. It is a luxury that my father (a retired pediatrician) did not have.
However, it is not unusual in the course of a busy workday to stumble upon what I deem "disinformation". Most of the time, it is simply loving, however misguided advice/warnings from a grandmother or aunt. The bulk of this "disinformation" comes in the form of old wives' tales that have been passed down from generation to generation, e.g. "not wearing socks will make a baby sick" or "green mucus needs antibiotics". For the sake of brevity, I will refrain from discoursing on why these adages are not scientifically accurate.
Suffice it to say, they are not true. However, neither statement is overtly precarious. Of course, should we start to treat (or continue in some cases) every green runny nose with antibiotics (most of which are viral in origin and thus do not require them), it would contribute significantly to the current surge in antibiotic resistant bacteria. However, case to case, it is hard to argue that a single misdirected prescription of Zithromax can be qualified as hazardous.
Other issues are more frustrating and ominous in nature. Of particular consequence is the issue of immunizations. This is often a touchy subject, which can at times evolve into an insurmountable divide between a family and their pediatrician. It is clear that in their short history in the world, vaccines have had their share of misgivings. Specific examples range from Rotashield-related cases of intussusception (a dangerous condition where your bowel involutes) to seizures related to whole-cell pertussis (whooping cough) vaccine. Both products have now been replaced with safer next-generation immunizations which have fared better in terms of safety profile.
Even with these setbacks, the overall safety profile for immunizations as a whole has been tremendously innocuous. What's more, the overall benefit to humanity is as Mastercard so aptly states: "priceless".
Per the CDC 2006:
"Vaccination is among the most significant public health success stories of all time. However, like any pharmaceutical product, no vaccine is completely safe or completely effective. While almost all known vaccine adverse events are minor and self-limited, some vaccines have been associated with very rare but serious health effects."
Even the CDC readily acknowledges serious side effects amongst the many success stories vaccines have enjoyed. In fact, if you pick up a copy of the regularly updated Bible of vaccines, Epidemiology and Prevention of Vaccine-Preventable Disease, it is refreshingly transparent about past side effects associated with particular immunizations.
The largest current scare to sweep the globe links autism to either the MMR vaccine (Measles, Mumps, Rubella) or thimerosal (a preservative which is currently being phased out in order to increase public confidence in vaccines). The initial stir begin following a 1998 Lancet article in which lead author Andrew Wakefield and colleagues posited a link between the MMR vaccine and autism.
Multiple studies by respectable scientific organizations have since been unable to validate any type of statistical correlation between either the MMR vaccine or thimerosal and autism. In fact, the Lancet journal (as well as 10 of the original 13 authors) itself has renounced the article that it originally published in 1998. Currently, Dr. Wakefield is facing multiple charges of medical ethical misconduct in the U.K. As for thimerosal - Denmark, a country that abandoned thimerosal as a preservative in 1991, actually saw an increase in autism beginning several years later.
Ultimately, I have no problem with a mother or father concerned about the possible deleterious effects of immunizations. Often, these parents are educated individuals who are well-informed and have nothing but the safety of their child in mind. Certainly no one can fault them for this. Furthermore, they have a reason to be antsy about vaccines. There has been some checkered success with certain immunizations in the past.
However, there has to be a filter through which a family decides who and what to believe. Often it is their pediatrician, who hopefully has gained their trust through a history of smart decision making and thoughtful care. And while there are internet sites galore which still tout the harm of MMR as a risk factor for autism, many of these sites rest the foundation of their case on an article which has since been widely discredited. Unfortunately in some cases, the newer data, rather than discrediting Dr. Wakefield, has conversely made him a martyr for parents not wanting to vaccinate their children.
At some point, these same parents hopefully will wonder why the vast majority of pediatricians continue to vaccinate their own children with the MMR vaccine. After all, if anyone has studied immunizations up close and personal, it is a pediatrician. Our education bound with the Hippocratic Oath hopefully qualifies our profession to make judicious decisions for each patient of ours. And like any loving parent, we do what we think is best for our own children. We just happen to have chosen a profession which equips us to be a little more discerning about what we come across on the world wide web. Hopefully, with well placed effort and knowledge we can do our part to keep informed opinion respectable in the era of the Information Age.
Friday, August 24, 2007
By "trusting" your pediatrician, you likely hope for a cost-effective yet effective, innocuous yet proven, thorough yet uncomplicated treatment each time your child becomes ill.
When presented with a sick child, there is a careful and structured thought process that I go through to come up with the best treatment plan. But before concocting a solution, I must first ascertain what the correct diagnosis is. I would estimate that 60% of the diagnoses I make each day are bread and butter pediatrics, simple enough such that an astute pediatric resident at the end of their 1st year of training could come up with the correct answer without assistance.
Another 30% of my patients may not present as cut and dry, but I can easily group them into an unofficial diagnostic category such as "viral illness with a funky rash which should resolve without any complication".
It is the final 10% where my experience, fund of knowledge and creativity come into play. And truth be told, the majority of this 10% will go on to good health, regardless of any intervention or medication. It is in this last 10% where follow-up visits are my most powerful and cost-effective ally.
Imagine you are a contestant on an updated version of the 5o's game show Name that Tune. If you are an iPod junkie, you may be able to correctly name 80% of songs with just a few bars of music. Certain songs are so distinct, that it wouldn't take even an average music fan but a few notes to decipher what they are listening to. Ala You Give Love a Bad Name, Hit Me with Your Best Shot, Play That Funky Music, White Boy, etc.
But other songs may take a few more lines. For example, the notorious Ice Ice Baby could easily be mixed up with Queen's classic song Under Pressure (not that Vanilla plagiarized. C'mon - he was keeping it real!). You get my point. Some diagnoses only take a few notes, others may require a follow-up visit or two.
At the end of a visit in which the diagnosis is not clear, a pediatrician can:
A. Order a battery of tests to shed some light on the matter.
B. Try medication(s)/treatment(s) and hope something works.
C. Consult a specialist.
D. Send the child to the ER.
E. Have the child return for a follow-up visit.
Each of these choices is appropriate in certain situations. However, each has a potential downside. Tests are often expensive and possibly harmful (radiation) or painful (blood draws). Medications can also be expensive and can lead to possible side effects. Specialists are often expensive as well and may feel compelled that the buck has to stop here, leading to unnecessary treatments/tests. The ER is insanely expensive, and you may have a less qualified doctor than your pediatrician helming the ship. Finally, a follow-up visit may be the most cost-effective measure; however, the child may become sicker or there may be no additional clues which present themselves at the follow-up visit.
The pediatrician must carefully choose which of these options is the most appropriate in each situation. If I think I have a bead on a possible diagnosis, I will sometimes order a test to see if I am correct. If I have a strong hunch on a possible diagnosis, I may even empirically treat. If I am perplexed, I may elicit the help of a specialist. If I am worried that a child is decompensating, I may send them to the ER. However, the most likely scenario is that I just need to see the history of the disease play itself out. And thus, it is the almighty follow-up visit which aids me the greatest in murky situations.
Once a child is deemed stable, a follow-up visit is usually the cheapest, most pain-free, side-effect free and hassle-free plan of action that can be taken for the family. Given that most kids are resilient, many will improve by the time they follow-up with me. Or in the event that they remain ill, a few more symptoms will surface to help make the proper diagnosis and treatment plan. Simply by waiting a few hours or days, I can avoid the egregious error of crediting Vanilla Ice with a true Queen classic. And all this whilst I am under pressure.
Thursday, August 16, 2007
As I have evolved as a pediatrician, I have come to appreciate how practicing medicine is truly an art. During my formative medical school years, I always pondered what people meant when they spoke of "the art of medicine".
As a pragmatic science-minded individual who majored in Biology, which lends itself to classifying everything, even when a species may pose a classification conundrum, I had viewed the world as black and white. Math made sense to me. Chemistry made sense to me. Picasso did not make sense to me.
So when I entered medical school in 1995, I assumed that medicine, having it's foundation built on science, would be as methodical and formulated as math and chemistry. The first 2 years of medical school confirmed my belief in this systematic world of diseases and drugs. Patient gets sick with disease, doctor makes diagnosis. Doctor prescribes medication, patient gets well.
And really, through my clinicals of medical school and later my early years of residency, medicine, for the most part, remained very systematic in my brain. I could barely keep up with trying to fill my head with formulas, decision trees, syndromes, treatment guides, etc. Barely wading with my cranium (I learned that word in med school!) above an ever increasing pool of facts and figures, I failed to take a breather to take a bird's eye view of pediatrics (or medicine in general).
As a resident, the fact that I was, for the most part, regurgitating orders from my attending superiors only further augmented my belief that the vast majority of medicine was based on a cookbook (albeit a rather large one). It was a cookbook that my superiors were familiar with and one which I would need to master.
This type of thinking was not only naive, it also carried an air of cockiness - a belief that Western medicine had for the most part completed this cookbook with all necessary recipes to ensure good health, long life, peace and happiness. Perhaps my first rude awakening from this rudimentary mindset arrived in the form of the common cold.
I was surprised to learn in residency that, for the most part, we as pediatricians had very little to offer the unfortunate individual afflicted with perhaps the world's most ubiquitous ailment, the upper respiratory infection. Modern medicine, for all its bells and whistles, could stop neither the running of the nose nor the coughing of the lungs. But what of all the wonderful ads and medications that I had seen lining the aisles of every Walmart? What about the previous winter when Nyquil held my hand during those torturous and snotty all-nighters? My mouth gaped open when I learned that it had all been the placebo effect.
Five years of private practice and fifty articles on cold medications later, it all seems so obvious to me that we as physicians have little to offer not only children, but their adult counterparts as well, when they catch a cold. What I have come to realize is that the best thing I can offer my parents when they bring their child in with a cold is "the art of medicine".
Really, what most moms are looking for is reassurance. Many are also looking for a good night's rest. Unfortunately, it is only the former that a good pediatrician can offer. So with a tired mother who has been up all night with a coughing child, a pediatrician must be delicate and artful in helping the mom (and/or dad, grandma, grandpa, Aunt Bessie, Uncle Ed, etc.) understand the natural history of the cold, realize the lack of evidence for cold medications, weigh the risk of side effects from cold medications vs. the zero benefit, and be attentive to the possible complications a cold can evolve into (such as pneumonia).
It is of particular importance to give mothers a clear contingency plan, such that they know what to look for should a child develop a secondary infection like pneumonia, an ear infection, or a sinus infection. I am infinitely better at this type of counseling now than when I started private practice 5 years ago. Or perhaps mothers are far more willing to listen to a pediatrician with 5 years of experience under his belt then a newbie straight out of residency. It is probably a little of both.
But just like there are politicians who are better at rhetoric and teachers who are better at explaining calculus, there are pediatricians who are better at putting a worried mom's mind to ease (assuming that the cold really is just a cold). It is the proper balance of a thorough exam
mixed with the sprinkling of the right factoids added to a clear contingency plan, that can allow a mother's mind to be at peace, even when she is up all night with her coughing child. And this is art.
Another way to understand the art of medicine is (and really it would take several more blogs to put this in proper perspective) to dissect a simple treatment plan for a simple ailment such as a middle ear infection. After making the correct diagnosis and educating the mother on what her child has, the next step is to come up with the proper treatment plan. And even with a rudimentary pediatric illness such as an ear infection, a proper treatment plan should be tailored to the individual family.
When a child is diagnosed with an ear infection, he should receive antibiotics (unless they are over 2 years of age, in which case there are other options. However, for the sake of simplicity, I will assume treatment is necessary). The doctor should then take into consideration many factors in coming up with the best plan. Are they cash pay or insurance? Are they going out of town this weekend? Can they follow-up? Are they allergic to penicillin? Can the child take oral medications without throwing up? Has this child had previous ear infections? Are there other underlying conditions to consider?
Answers to each of these questions can and should sway the physician to tailor the plan to meet the needs and desires of the parent(s). And in order to create the proper plan or the "best" plan, it requires not only a strong fund of knowledge to pull from, but also a creative mind (and likely a compassionate mind) as well to fit each scenario as best as possible. And here again it is the "art of medicine" that can separate the good physician from the special one.