Post#2 The Power of Follow-up

Of the many doctors that will one day infiltrate your life and perhaps your body, you as an individual/mother/father/caretaker will no doubt ask yourself, "Do I trust this doctor?" It is a fair and necessary question. But it is likely that of all the M.D.s who come in and out of your life, the one who you will scrutinize the hardest is your pediatrician (and perhaps your OB/Gyn). And for good reason - they are your partners in caring for what is likely the most important thing in your life, your child. And you pray and hope they don't screw up. Talk about pressure.

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.

Post#1 The Art of Medicine

A long initial blog to get things rolling. . . I will work at word/thought economy henceforth.

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.