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The balm of reassurance
A toddler has had several brief episodes of mild perioral cyanosis noticed at day care. The parents see the primary care provider. The exam is normal. The child is admitted for a work-up. The CBC and comprehensive metabolic profile are unremarkable. The chest x-ray is normal. An ECG is normal. An echocardiogram is normal. The EEG is normal. Now what?
I was taught that an uncommon presentation of a common disease is still more common than a common presentation of an uncommon disease. Or simply, odd-looking horses are more common than zebras unless you practice in the savanna. There is a point in any safari at which you have to decide whether you are hunting a zebra or chasing a shadow. Clinical judgment is balancing the risk of missing something preventable that will actually harm the child against the harms of more tests.
The modern hospital has an array of equipment available. They are Greek Sirens calling to us. There is the video EEG room, the MR angiogram, the cardiac cath lab, and an endless list of blood tests. We are not even stopped by the walls of the hospital. We can order a follow-up ambulatory Holter ECG to search for intermittent arrhythmias. But are these Sirens really good medicine? At what point should we simply reassure the parents that the child is fine?
Physicians all worry about missing something. This fear was instilled when we were medical students and reinforced with the stress of residency. With years of experience, all physicians acquire a list of missed diagnoses. But I also have collected a list of times when the diagnostic tests themselves have caused harm, including death. I have a list of cases where nonspecific diagnostic testing has mislabeled a child with an obscure diagnosis that was later proven false, but not before harm was caused. There were patients with Stevens-Johnson syndrome who suffered serious harm from treatments for minor illnesses. Then there were the terrified families who, after extensive testing, became convinced that the child must have some horrible unknown disease because surely we wouldn’t have traumatized the child with all this work-up if there wasn’t really something seriously wrong. Each new test stoked their fear rather than soothed it.
A careful history is still the weapon of choice in the zebra hunt. On a first presentation of mild cyanosis, sepsis is the charging rhinoceros of preventable harm that will run you over if you are too slow to react. But this child has now had several episodes that have occurred: 1. in multiple settings, 2. with no distress, 3. while the child remained playful, and 4. that were self-limited. That history is incompatible with sepsis, so reflexively ordering a blood culture is an illogical choice. The history should be progressively explored using the differential diagnosis and an organ-based systematic approach to guide it. The thoroughness and thoughtfulness I put into the history taking can be key to finding the correct diagnosis. They also are a means of building trust and rapport with the parents. That will be important later if no definitive diagnosis is found.
Unclear and unusual presentations may merit a consult. The cardiologist knows the limits of an echo. Along with the technical expertise comes a new set of eyes and the additional perspective of a second opinion. It is great when a colleague can tell you that he or she too had a case like this years ago that was never solved, but did resolve on its own.
One advantage of being an office-based pediatrician, with an established relationship with a family over several years and a couple other children, is that parents do value and trust your clinical judgment. As a pediatrician, I know the most common product I sell is reassurance. It is not snake oil. There is a bedside manner in selling it. Put a positive spin on all the negative tests. Indicate that you and the parents can be vigilant in watching for new signs. Instruct the parents to bring the child back if the events are distressing for the child, which could justify more invasive testing. Arrange to recheck the child in the office in a week, then a month, then at the next well visit. Parents know that medicine isn’t perfect. Humans deal with fear and uncertainty better by knowing we aren’t facing the future alone. And that is why even with all this technology, I still lay a stethoscope on every child.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures.
A toddler has had several brief episodes of mild perioral cyanosis noticed at day care. The parents see the primary care provider. The exam is normal. The child is admitted for a work-up. The CBC and comprehensive metabolic profile are unremarkable. The chest x-ray is normal. An ECG is normal. An echocardiogram is normal. The EEG is normal. Now what?
I was taught that an uncommon presentation of a common disease is still more common than a common presentation of an uncommon disease. Or simply, odd-looking horses are more common than zebras unless you practice in the savanna. There is a point in any safari at which you have to decide whether you are hunting a zebra or chasing a shadow. Clinical judgment is balancing the risk of missing something preventable that will actually harm the child against the harms of more tests.
The modern hospital has an array of equipment available. They are Greek Sirens calling to us. There is the video EEG room, the MR angiogram, the cardiac cath lab, and an endless list of blood tests. We are not even stopped by the walls of the hospital. We can order a follow-up ambulatory Holter ECG to search for intermittent arrhythmias. But are these Sirens really good medicine? At what point should we simply reassure the parents that the child is fine?
Physicians all worry about missing something. This fear was instilled when we were medical students and reinforced with the stress of residency. With years of experience, all physicians acquire a list of missed diagnoses. But I also have collected a list of times when the diagnostic tests themselves have caused harm, including death. I have a list of cases where nonspecific diagnostic testing has mislabeled a child with an obscure diagnosis that was later proven false, but not before harm was caused. There were patients with Stevens-Johnson syndrome who suffered serious harm from treatments for minor illnesses. Then there were the terrified families who, after extensive testing, became convinced that the child must have some horrible unknown disease because surely we wouldn’t have traumatized the child with all this work-up if there wasn’t really something seriously wrong. Each new test stoked their fear rather than soothed it.
A careful history is still the weapon of choice in the zebra hunt. On a first presentation of mild cyanosis, sepsis is the charging rhinoceros of preventable harm that will run you over if you are too slow to react. But this child has now had several episodes that have occurred: 1. in multiple settings, 2. with no distress, 3. while the child remained playful, and 4. that were self-limited. That history is incompatible with sepsis, so reflexively ordering a blood culture is an illogical choice. The history should be progressively explored using the differential diagnosis and an organ-based systematic approach to guide it. The thoroughness and thoughtfulness I put into the history taking can be key to finding the correct diagnosis. They also are a means of building trust and rapport with the parents. That will be important later if no definitive diagnosis is found.
Unclear and unusual presentations may merit a consult. The cardiologist knows the limits of an echo. Along with the technical expertise comes a new set of eyes and the additional perspective of a second opinion. It is great when a colleague can tell you that he or she too had a case like this years ago that was never solved, but did resolve on its own.
One advantage of being an office-based pediatrician, with an established relationship with a family over several years and a couple other children, is that parents do value and trust your clinical judgment. As a pediatrician, I know the most common product I sell is reassurance. It is not snake oil. There is a bedside manner in selling it. Put a positive spin on all the negative tests. Indicate that you and the parents can be vigilant in watching for new signs. Instruct the parents to bring the child back if the events are distressing for the child, which could justify more invasive testing. Arrange to recheck the child in the office in a week, then a month, then at the next well visit. Parents know that medicine isn’t perfect. Humans deal with fear and uncertainty better by knowing we aren’t facing the future alone. And that is why even with all this technology, I still lay a stethoscope on every child.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures.
A toddler has had several brief episodes of mild perioral cyanosis noticed at day care. The parents see the primary care provider. The exam is normal. The child is admitted for a work-up. The CBC and comprehensive metabolic profile are unremarkable. The chest x-ray is normal. An ECG is normal. An echocardiogram is normal. The EEG is normal. Now what?
I was taught that an uncommon presentation of a common disease is still more common than a common presentation of an uncommon disease. Or simply, odd-looking horses are more common than zebras unless you practice in the savanna. There is a point in any safari at which you have to decide whether you are hunting a zebra or chasing a shadow. Clinical judgment is balancing the risk of missing something preventable that will actually harm the child against the harms of more tests.
The modern hospital has an array of equipment available. They are Greek Sirens calling to us. There is the video EEG room, the MR angiogram, the cardiac cath lab, and an endless list of blood tests. We are not even stopped by the walls of the hospital. We can order a follow-up ambulatory Holter ECG to search for intermittent arrhythmias. But are these Sirens really good medicine? At what point should we simply reassure the parents that the child is fine?
Physicians all worry about missing something. This fear was instilled when we were medical students and reinforced with the stress of residency. With years of experience, all physicians acquire a list of missed diagnoses. But I also have collected a list of times when the diagnostic tests themselves have caused harm, including death. I have a list of cases where nonspecific diagnostic testing has mislabeled a child with an obscure diagnosis that was later proven false, but not before harm was caused. There were patients with Stevens-Johnson syndrome who suffered serious harm from treatments for minor illnesses. Then there were the terrified families who, after extensive testing, became convinced that the child must have some horrible unknown disease because surely we wouldn’t have traumatized the child with all this work-up if there wasn’t really something seriously wrong. Each new test stoked their fear rather than soothed it.
A careful history is still the weapon of choice in the zebra hunt. On a first presentation of mild cyanosis, sepsis is the charging rhinoceros of preventable harm that will run you over if you are too slow to react. But this child has now had several episodes that have occurred: 1. in multiple settings, 2. with no distress, 3. while the child remained playful, and 4. that were self-limited. That history is incompatible with sepsis, so reflexively ordering a blood culture is an illogical choice. The history should be progressively explored using the differential diagnosis and an organ-based systematic approach to guide it. The thoroughness and thoughtfulness I put into the history taking can be key to finding the correct diagnosis. They also are a means of building trust and rapport with the parents. That will be important later if no definitive diagnosis is found.
Unclear and unusual presentations may merit a consult. The cardiologist knows the limits of an echo. Along with the technical expertise comes a new set of eyes and the additional perspective of a second opinion. It is great when a colleague can tell you that he or she too had a case like this years ago that was never solved, but did resolve on its own.
One advantage of being an office-based pediatrician, with an established relationship with a family over several years and a couple other children, is that parents do value and trust your clinical judgment. As a pediatrician, I know the most common product I sell is reassurance. It is not snake oil. There is a bedside manner in selling it. Put a positive spin on all the negative tests. Indicate that you and the parents can be vigilant in watching for new signs. Instruct the parents to bring the child back if the events are distressing for the child, which could justify more invasive testing. Arrange to recheck the child in the office in a week, then a month, then at the next well visit. Parents know that medicine isn’t perfect. Humans deal with fear and uncertainty better by knowing we aren’t facing the future alone. And that is why even with all this technology, I still lay a stethoscope on every child.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures.
Slaying the dragon of false research
John Ioannidis was introduced as a rock star. To the congregation at the 2016 Lown Institute Conference in Chicago, that is what he is. The Stanford University professor is most famous for the heavily cited (over 2,000 citations so far) paper in PLoS Medicine, titled, “Why Most Published Research Findings Are False.”1 The cheering audience of clinicians, researchers, community organizers, and patient advocates were obviously familiar with the work. His message about the poor state of medical research and the inaccurate application of evidence-based medicine resonated with this audience. The conference’s emphasis was on Right Care, a balance between the many benefits of modern medical care and the harms of overdiagnosis and overtreatment. There are many similar initiatives in medicine. For instance, in 2012 the American Board of Internal Medicine Foundation launched Choosing Wisely “with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.”2 The U.S. Preventive Services Task Force has been issuing many recommendations recently. Several of those have counseled reducing screening and treatment rather than touting medical advances.
Pediatric hospital medicine (PHM) is a leader in this value medicine movement. Pediatricians are aware of the emotional trauma of procedures and hospitalizations, of the harm caused by radiation exposure, and of the phobia and dread of needle pokes. Primum non nocere.
The medical care system has contributed to the improvement in life expectancy over the last 50 years. The life expectancy for U.S. adults has increased about 3-4 years during that interval, although it is unclear what fraction of that is attributable to medical care. The per capita cost of the U.S. health care system is far greater than in other democratic developed countries, so we probably spend most of those extra 3-4 years working to pay for it. Government health care contributes heavily to the national debt. That is important because, despite all the technological advances in medicine, the socioeconomic determinants of health are far more important.3 So if we are wasting money on ineffective care, we can improve health by safely doing less.
A recently released article documents a salient example of inaccurate research leading to ineffective treatment. For over five winters, the pediatric hospitalist community has been debating whether nebulized hypertonic saline is beneficial for infants hospitalized with bronchiolitis. At a pro/con SmackDown debate at the 2011 PHM conference, both of the speakers were cautious in presenting their side of the debate. Nebulized hypertonic saline is effective for improving pulmonary clearance of the thick mucus of older children with cystic fibrosis. A few initial studies had shown conflicting but promising responses for infants with bronchiolitis, but the studies were underpowered and used disparate methods.
Since then, the accumulated evidence has been disappointing. Many additional small, underpowered studies were published in 2013-2014. A total of 18 studies were included in the latest meta-analysis by Brooks, Harrison, and Ralston, published online as “Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses” in JAMA Pediatrics.4
Meta-analyses often obscure important differences among the studies they are combining, resulting in comparing apples and oranges, or worse creating fruit salad. But in a tour de force analysis, this article did not hand wave away all the typical statistical assumptions made by the average published meta-analysis. The intrepid authors examined the differences among the publications and calculated that those studies were too heterogeneous to be combined simply. When studied in more depth, two publications from one study population in China were outliers. The average length of stay was much longer in that study. Among the remaining papers, there was a residual correlation in which the studies leaning toward showing benefit had admitted the treatment population later in the course of the illness.
After adjustment for these anomalies, the conclusion was that the nebulized hypertonic saline treatment did not produce a clinically significant benefit. After years of debate on the hospitalist Listserv, this new article had one commentator pronouncing the end of using nebulized hypertonic saline for hospitalized infants with bronchiolitis and asserting that the issue could now rest in peace.
References
1. PLoS Med. 2005. doi: 10.1371/journal.pmed.0020124.
4. JAMA Pediatr. 2016 Apr 18. doi: 10.1001/jamapediatrics.2016.0079.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
John Ioannidis was introduced as a rock star. To the congregation at the 2016 Lown Institute Conference in Chicago, that is what he is. The Stanford University professor is most famous for the heavily cited (over 2,000 citations so far) paper in PLoS Medicine, titled, “Why Most Published Research Findings Are False.”1 The cheering audience of clinicians, researchers, community organizers, and patient advocates were obviously familiar with the work. His message about the poor state of medical research and the inaccurate application of evidence-based medicine resonated with this audience. The conference’s emphasis was on Right Care, a balance between the many benefits of modern medical care and the harms of overdiagnosis and overtreatment. There are many similar initiatives in medicine. For instance, in 2012 the American Board of Internal Medicine Foundation launched Choosing Wisely “with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.”2 The U.S. Preventive Services Task Force has been issuing many recommendations recently. Several of those have counseled reducing screening and treatment rather than touting medical advances.
Pediatric hospital medicine (PHM) is a leader in this value medicine movement. Pediatricians are aware of the emotional trauma of procedures and hospitalizations, of the harm caused by radiation exposure, and of the phobia and dread of needle pokes. Primum non nocere.
The medical care system has contributed to the improvement in life expectancy over the last 50 years. The life expectancy for U.S. adults has increased about 3-4 years during that interval, although it is unclear what fraction of that is attributable to medical care. The per capita cost of the U.S. health care system is far greater than in other democratic developed countries, so we probably spend most of those extra 3-4 years working to pay for it. Government health care contributes heavily to the national debt. That is important because, despite all the technological advances in medicine, the socioeconomic determinants of health are far more important.3 So if we are wasting money on ineffective care, we can improve health by safely doing less.
A recently released article documents a salient example of inaccurate research leading to ineffective treatment. For over five winters, the pediatric hospitalist community has been debating whether nebulized hypertonic saline is beneficial for infants hospitalized with bronchiolitis. At a pro/con SmackDown debate at the 2011 PHM conference, both of the speakers were cautious in presenting their side of the debate. Nebulized hypertonic saline is effective for improving pulmonary clearance of the thick mucus of older children with cystic fibrosis. A few initial studies had shown conflicting but promising responses for infants with bronchiolitis, but the studies were underpowered and used disparate methods.
Since then, the accumulated evidence has been disappointing. Many additional small, underpowered studies were published in 2013-2014. A total of 18 studies were included in the latest meta-analysis by Brooks, Harrison, and Ralston, published online as “Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses” in JAMA Pediatrics.4
Meta-analyses often obscure important differences among the studies they are combining, resulting in comparing apples and oranges, or worse creating fruit salad. But in a tour de force analysis, this article did not hand wave away all the typical statistical assumptions made by the average published meta-analysis. The intrepid authors examined the differences among the publications and calculated that those studies were too heterogeneous to be combined simply. When studied in more depth, two publications from one study population in China were outliers. The average length of stay was much longer in that study. Among the remaining papers, there was a residual correlation in which the studies leaning toward showing benefit had admitted the treatment population later in the course of the illness.
After adjustment for these anomalies, the conclusion was that the nebulized hypertonic saline treatment did not produce a clinically significant benefit. After years of debate on the hospitalist Listserv, this new article had one commentator pronouncing the end of using nebulized hypertonic saline for hospitalized infants with bronchiolitis and asserting that the issue could now rest in peace.
References
1. PLoS Med. 2005. doi: 10.1371/journal.pmed.0020124.
4. JAMA Pediatr. 2016 Apr 18. doi: 10.1001/jamapediatrics.2016.0079.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
John Ioannidis was introduced as a rock star. To the congregation at the 2016 Lown Institute Conference in Chicago, that is what he is. The Stanford University professor is most famous for the heavily cited (over 2,000 citations so far) paper in PLoS Medicine, titled, “Why Most Published Research Findings Are False.”1 The cheering audience of clinicians, researchers, community organizers, and patient advocates were obviously familiar with the work. His message about the poor state of medical research and the inaccurate application of evidence-based medicine resonated with this audience. The conference’s emphasis was on Right Care, a balance between the many benefits of modern medical care and the harms of overdiagnosis and overtreatment. There are many similar initiatives in medicine. For instance, in 2012 the American Board of Internal Medicine Foundation launched Choosing Wisely “with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.”2 The U.S. Preventive Services Task Force has been issuing many recommendations recently. Several of those have counseled reducing screening and treatment rather than touting medical advances.
Pediatric hospital medicine (PHM) is a leader in this value medicine movement. Pediatricians are aware of the emotional trauma of procedures and hospitalizations, of the harm caused by radiation exposure, and of the phobia and dread of needle pokes. Primum non nocere.
The medical care system has contributed to the improvement in life expectancy over the last 50 years. The life expectancy for U.S. adults has increased about 3-4 years during that interval, although it is unclear what fraction of that is attributable to medical care. The per capita cost of the U.S. health care system is far greater than in other democratic developed countries, so we probably spend most of those extra 3-4 years working to pay for it. Government health care contributes heavily to the national debt. That is important because, despite all the technological advances in medicine, the socioeconomic determinants of health are far more important.3 So if we are wasting money on ineffective care, we can improve health by safely doing less.
A recently released article documents a salient example of inaccurate research leading to ineffective treatment. For over five winters, the pediatric hospitalist community has been debating whether nebulized hypertonic saline is beneficial for infants hospitalized with bronchiolitis. At a pro/con SmackDown debate at the 2011 PHM conference, both of the speakers were cautious in presenting their side of the debate. Nebulized hypertonic saline is effective for improving pulmonary clearance of the thick mucus of older children with cystic fibrosis. A few initial studies had shown conflicting but promising responses for infants with bronchiolitis, but the studies were underpowered and used disparate methods.
Since then, the accumulated evidence has been disappointing. Many additional small, underpowered studies were published in 2013-2014. A total of 18 studies were included in the latest meta-analysis by Brooks, Harrison, and Ralston, published online as “Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses” in JAMA Pediatrics.4
Meta-analyses often obscure important differences among the studies they are combining, resulting in comparing apples and oranges, or worse creating fruit salad. But in a tour de force analysis, this article did not hand wave away all the typical statistical assumptions made by the average published meta-analysis. The intrepid authors examined the differences among the publications and calculated that those studies were too heterogeneous to be combined simply. When studied in more depth, two publications from one study population in China were outliers. The average length of stay was much longer in that study. Among the remaining papers, there was a residual correlation in which the studies leaning toward showing benefit had admitted the treatment population later in the course of the illness.
After adjustment for these anomalies, the conclusion was that the nebulized hypertonic saline treatment did not produce a clinically significant benefit. After years of debate on the hospitalist Listserv, this new article had one commentator pronouncing the end of using nebulized hypertonic saline for hospitalized infants with bronchiolitis and asserting that the issue could now rest in peace.
References
1. PLoS Med. 2005. doi: 10.1371/journal.pmed.0020124.
4. JAMA Pediatr. 2016 Apr 18. doi: 10.1001/jamapediatrics.2016.0079.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
End of life care
As the busy days of a long, gray winter drag on and an early season of Lent has begun, this column flows from reflections on life, death, and the promise of a new season of spring and green trees, hopefully coming soon – no matter what that groundhog saw.
Clinical ethics consultation often involves end of life (EOL) care. When I recall patients from my career, many memories are of patients who died. I trained with an intensivist who said he felt he was under less stress than the general pediatricians. While his patients were sicker, if one of his patients died, it was not unexpected. The presumption was that in the ICU everything possible had been done. General pediatricians rarely have a patient who dies. When they do, everyone, including the pediatrician, will ponder over whether something might have been caught earlier or something could have been done differently. But the most difficult problems in pediatric EOL care involve deciding when to stop aggressive care and let nature take its course.
I think the natural tendency for scholars is to approach difficult decisions by seeking more information. The delusion (which scholars can usually elucidate in great postmodern detail as long as it doesn’t apply to our own behavior) is that extensive information and deep reflection will lead to the best, most accurate, immutable, and nonambivalent declaration of goals, desires, values, and intents. To even make this delusion plausible, a sci-fi writer had to create a nonhuman species of Vulcans. But medical ethicists routinely apply this paradigm to existentially frightening EOL matters in a medical world full of prognostic uncertainty. Ethicists have recommended that this method of decision making be adopted by a population with low health literacy and a predilection to using Tinder.
For the internists, EOL care is mostly about specifying which modalities to use and which to limit. Over time, it became evident that a single check box, labeled Do Not Resuscitate yes/no, was insufficient to capture patient preferences. I recall once seeing a draft document with 49 boxes. It was clearly unwieldy. Most states that have adopted a POLST (Physician Orders for Life-Sustaining Treatment) paradigm have settled for forms with five to seven options. I think that if it were possible to capture advance directives better than that, eharmony.com, with its plethora of questions, would have already created an app for it. In adult medicine, we always can lament that the conversation about EOL care was too brief, but in my experience raising expectations of a more comprehensive discussion usually lowers the likelihood of people ever undertaking even an abbreviated conversation. In ethics, if you raise the bar high enough, people seem to walk under it.
Pediatrics at the EOL tends to focus discussion more on the goals of care, the likely outcomes, and the quality of life. These perspectives are then sometimes mapped, with poor reliability, onto the POLST paradigm designed for adults. Parents are usually at the bedside often enough to recognize their child’s suffering during aggressive care. Surrogate decision makers for adult EOL care occasionally lack that insight.
While advance directive documents are helpful, I don’t think there is a substitute for a physician motivated by empathy and a caring, involved surrogate decision maker at bedside. Providing information is not the key focus. The process should emphasize building trusting relationships, clear understanding, and reasonable expectations. I am reminded in those situations of an ancient quote: Medical care is “to cure sometimes, to relieve often, and to comfort always.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
As the busy days of a long, gray winter drag on and an early season of Lent has begun, this column flows from reflections on life, death, and the promise of a new season of spring and green trees, hopefully coming soon – no matter what that groundhog saw.
Clinical ethics consultation often involves end of life (EOL) care. When I recall patients from my career, many memories are of patients who died. I trained with an intensivist who said he felt he was under less stress than the general pediatricians. While his patients were sicker, if one of his patients died, it was not unexpected. The presumption was that in the ICU everything possible had been done. General pediatricians rarely have a patient who dies. When they do, everyone, including the pediatrician, will ponder over whether something might have been caught earlier or something could have been done differently. But the most difficult problems in pediatric EOL care involve deciding when to stop aggressive care and let nature take its course.
I think the natural tendency for scholars is to approach difficult decisions by seeking more information. The delusion (which scholars can usually elucidate in great postmodern detail as long as it doesn’t apply to our own behavior) is that extensive information and deep reflection will lead to the best, most accurate, immutable, and nonambivalent declaration of goals, desires, values, and intents. To even make this delusion plausible, a sci-fi writer had to create a nonhuman species of Vulcans. But medical ethicists routinely apply this paradigm to existentially frightening EOL matters in a medical world full of prognostic uncertainty. Ethicists have recommended that this method of decision making be adopted by a population with low health literacy and a predilection to using Tinder.
For the internists, EOL care is mostly about specifying which modalities to use and which to limit. Over time, it became evident that a single check box, labeled Do Not Resuscitate yes/no, was insufficient to capture patient preferences. I recall once seeing a draft document with 49 boxes. It was clearly unwieldy. Most states that have adopted a POLST (Physician Orders for Life-Sustaining Treatment) paradigm have settled for forms with five to seven options. I think that if it were possible to capture advance directives better than that, eharmony.com, with its plethora of questions, would have already created an app for it. In adult medicine, we always can lament that the conversation about EOL care was too brief, but in my experience raising expectations of a more comprehensive discussion usually lowers the likelihood of people ever undertaking even an abbreviated conversation. In ethics, if you raise the bar high enough, people seem to walk under it.
Pediatrics at the EOL tends to focus discussion more on the goals of care, the likely outcomes, and the quality of life. These perspectives are then sometimes mapped, with poor reliability, onto the POLST paradigm designed for adults. Parents are usually at the bedside often enough to recognize their child’s suffering during aggressive care. Surrogate decision makers for adult EOL care occasionally lack that insight.
While advance directive documents are helpful, I don’t think there is a substitute for a physician motivated by empathy and a caring, involved surrogate decision maker at bedside. Providing information is not the key focus. The process should emphasize building trusting relationships, clear understanding, and reasonable expectations. I am reminded in those situations of an ancient quote: Medical care is “to cure sometimes, to relieve often, and to comfort always.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
As the busy days of a long, gray winter drag on and an early season of Lent has begun, this column flows from reflections on life, death, and the promise of a new season of spring and green trees, hopefully coming soon – no matter what that groundhog saw.
Clinical ethics consultation often involves end of life (EOL) care. When I recall patients from my career, many memories are of patients who died. I trained with an intensivist who said he felt he was under less stress than the general pediatricians. While his patients were sicker, if one of his patients died, it was not unexpected. The presumption was that in the ICU everything possible had been done. General pediatricians rarely have a patient who dies. When they do, everyone, including the pediatrician, will ponder over whether something might have been caught earlier or something could have been done differently. But the most difficult problems in pediatric EOL care involve deciding when to stop aggressive care and let nature take its course.
I think the natural tendency for scholars is to approach difficult decisions by seeking more information. The delusion (which scholars can usually elucidate in great postmodern detail as long as it doesn’t apply to our own behavior) is that extensive information and deep reflection will lead to the best, most accurate, immutable, and nonambivalent declaration of goals, desires, values, and intents. To even make this delusion plausible, a sci-fi writer had to create a nonhuman species of Vulcans. But medical ethicists routinely apply this paradigm to existentially frightening EOL matters in a medical world full of prognostic uncertainty. Ethicists have recommended that this method of decision making be adopted by a population with low health literacy and a predilection to using Tinder.
For the internists, EOL care is mostly about specifying which modalities to use and which to limit. Over time, it became evident that a single check box, labeled Do Not Resuscitate yes/no, was insufficient to capture patient preferences. I recall once seeing a draft document with 49 boxes. It was clearly unwieldy. Most states that have adopted a POLST (Physician Orders for Life-Sustaining Treatment) paradigm have settled for forms with five to seven options. I think that if it were possible to capture advance directives better than that, eharmony.com, with its plethora of questions, would have already created an app for it. In adult medicine, we always can lament that the conversation about EOL care was too brief, but in my experience raising expectations of a more comprehensive discussion usually lowers the likelihood of people ever undertaking even an abbreviated conversation. In ethics, if you raise the bar high enough, people seem to walk under it.
Pediatrics at the EOL tends to focus discussion more on the goals of care, the likely outcomes, and the quality of life. These perspectives are then sometimes mapped, with poor reliability, onto the POLST paradigm designed for adults. Parents are usually at the bedside often enough to recognize their child’s suffering during aggressive care. Surrogate decision makers for adult EOL care occasionally lack that insight.
While advance directive documents are helpful, I don’t think there is a substitute for a physician motivated by empathy and a caring, involved surrogate decision maker at bedside. Providing information is not the key focus. The process should emphasize building trusting relationships, clear understanding, and reasonable expectations. I am reminded in those situations of an ancient quote: Medical care is “to cure sometimes, to relieve often, and to comfort always.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
Stewardship at 3 a.m.
The 3-month-old infant presents to the emergency department with a fever of 101° F. The emergency physician decides the infant looks ill enough to warrant some investigation. A urinalysis indicates a urinary tract infection. I am consulted to complete the admission to the hospital. The question arises, “Is a lumbar puncture indicated to rule out meningitis?”
I’ve been down this pathway many times. For years I have relied on a meta-analysis which corrected the bias of an old article from 1972.1 Multiple studies in the 2000-2010 time frame have shown that the risk of concurrent meningitis in a young infant with a UTI is vanishingly small. It is much less than 2%, with many studies finding 0%. So on a typical day, my answer is no tap if there is no clinical suggestion of meningitis.
Hospital medicine has recently focused on reducing overdiagnosis and overtreatment. When you only occasionally admit patients to the hospital, untoward events appear random and uncommon. When you work there day in and day out, you appreciate that all medical interventions have risks and costs.
A recent editorial raised the question of stewardship in medicine.2 It asked why physicians would choose a very expensive drug when there is little evidence of its superiority over a much cheaper predecessor. Physicians, whose actions influence a $3 trillion industry, have not embraced stewardship as a major component of their professional responsibilities. The physician does have a fiduciary duty toward the patient. The physician recommends the best care possible to achieve the patient’s goals of care. Dentistry is distinctly different in this regard. Dentists often have several ways of repairing decayed teeth. Various types of fillings are available. Gold fillings are more expensive. Newer implants are several times more expensive than crowns. Dentists routinely adjust their treatment plan based on what the patient can afford.
While most other industries have market competition and profitability as incentives to avoid extravagance, U.S. health care seems unbridled by fiscal responsibility. The news that a small pharmaceutical company had raised the price of an old generic antibiotic by 5000%3 exposed the irrationality and capriciousness4 of the pricing of medications in the United States. Many politicians decried the behavior but to little effect. Most consumer products, especially computers, become more powerful and cheaper with each decade. Health care does not follow this pattern
There are many factors that influence physician behavior. Concerns about malpractice may bias physicians toward expensive overtreatment. Modern medical research is usually published expounding on the benefits of a new technology over a previous therapy without any acknowledgment that the newer and more expensive treatment may have a downside. This biases people to use the latest and greatest treatment even though it may have only demonstrated noninferiority in its trials.
I try to use evidence-based medicine when it is available. In the clinical case described earlier, I indicate to the emergency doctor that unless there is a clinical impression of coexisting meningitis, the lumbar puncture is not indicated. I cite the meta-analysis as I have many times before. But this night is different. I am simultaneously admitting a teenager whose gastrostomy tube had become dislodged and couldn’t be replaced. This neurologically devastated child had had meningitis as an infant. He is a stark reminder of the consequences of a missed diagnosis.
The parents of that child have provided him wonderful care. His skin is in excellent condition. His moderate contractures are testimony to dedicated stretching regimens at home. It is evident that the parents love the child as he is. But I am sure they would give anything to have avoided this scenario and to reverse the consequences of that meningitis. And so, the best evidence we have, that the risk of meningitis in an infant is low, is not as reassuring to me on this night. At 3 a.m., the juxtaposition of the two patients is unsettling. Is the risk low enough? Would that new test5, serum procalcitonin, help me to make a better decision? How certain must I be that an intervention is unnecessary?
Health care policy, economics, and practice guidelines can be debated with detached objectivity around a conference table in the middle of the day. The trepidation in an emergency room at 3 a.m. is different. This is my patient. I am his doctor. That is the heart of medical ethics.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
References
1. “How common is co-existing meningitis in infants with urinary tract infection?” on Bestbets.org.
2. “Why do doctors choose a $2,000 cure when a $50 one is just as good?” by Andrew Lam, Washington Post, Dec. 10, 2015.
3. “Drug Goes From $13.50 a Tablet to $750, Overnight” by Andrew Pollack, New York Times, Sept. 20, 2015.
4. “How an $84,000 drug got its price: ‘Let’s hold our position … whatever the headlines’ ” by Carolyn Y. Johnson and Brady Dennis, Washington Post, Dec. 1, 2015.
5. JAMA Pediatr. Published online, 2015 Nov 23. doi:10.1001/jamapediatrics.2015.3267.
The 3-month-old infant presents to the emergency department with a fever of 101° F. The emergency physician decides the infant looks ill enough to warrant some investigation. A urinalysis indicates a urinary tract infection. I am consulted to complete the admission to the hospital. The question arises, “Is a lumbar puncture indicated to rule out meningitis?”
I’ve been down this pathway many times. For years I have relied on a meta-analysis which corrected the bias of an old article from 1972.1 Multiple studies in the 2000-2010 time frame have shown that the risk of concurrent meningitis in a young infant with a UTI is vanishingly small. It is much less than 2%, with many studies finding 0%. So on a typical day, my answer is no tap if there is no clinical suggestion of meningitis.
Hospital medicine has recently focused on reducing overdiagnosis and overtreatment. When you only occasionally admit patients to the hospital, untoward events appear random and uncommon. When you work there day in and day out, you appreciate that all medical interventions have risks and costs.
A recent editorial raised the question of stewardship in medicine.2 It asked why physicians would choose a very expensive drug when there is little evidence of its superiority over a much cheaper predecessor. Physicians, whose actions influence a $3 trillion industry, have not embraced stewardship as a major component of their professional responsibilities. The physician does have a fiduciary duty toward the patient. The physician recommends the best care possible to achieve the patient’s goals of care. Dentistry is distinctly different in this regard. Dentists often have several ways of repairing decayed teeth. Various types of fillings are available. Gold fillings are more expensive. Newer implants are several times more expensive than crowns. Dentists routinely adjust their treatment plan based on what the patient can afford.
While most other industries have market competition and profitability as incentives to avoid extravagance, U.S. health care seems unbridled by fiscal responsibility. The news that a small pharmaceutical company had raised the price of an old generic antibiotic by 5000%3 exposed the irrationality and capriciousness4 of the pricing of medications in the United States. Many politicians decried the behavior but to little effect. Most consumer products, especially computers, become more powerful and cheaper with each decade. Health care does not follow this pattern
There are many factors that influence physician behavior. Concerns about malpractice may bias physicians toward expensive overtreatment. Modern medical research is usually published expounding on the benefits of a new technology over a previous therapy without any acknowledgment that the newer and more expensive treatment may have a downside. This biases people to use the latest and greatest treatment even though it may have only demonstrated noninferiority in its trials.
I try to use evidence-based medicine when it is available. In the clinical case described earlier, I indicate to the emergency doctor that unless there is a clinical impression of coexisting meningitis, the lumbar puncture is not indicated. I cite the meta-analysis as I have many times before. But this night is different. I am simultaneously admitting a teenager whose gastrostomy tube had become dislodged and couldn’t be replaced. This neurologically devastated child had had meningitis as an infant. He is a stark reminder of the consequences of a missed diagnosis.
The parents of that child have provided him wonderful care. His skin is in excellent condition. His moderate contractures are testimony to dedicated stretching regimens at home. It is evident that the parents love the child as he is. But I am sure they would give anything to have avoided this scenario and to reverse the consequences of that meningitis. And so, the best evidence we have, that the risk of meningitis in an infant is low, is not as reassuring to me on this night. At 3 a.m., the juxtaposition of the two patients is unsettling. Is the risk low enough? Would that new test5, serum procalcitonin, help me to make a better decision? How certain must I be that an intervention is unnecessary?
Health care policy, economics, and practice guidelines can be debated with detached objectivity around a conference table in the middle of the day. The trepidation in an emergency room at 3 a.m. is different. This is my patient. I am his doctor. That is the heart of medical ethics.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
References
1. “How common is co-existing meningitis in infants with urinary tract infection?” on Bestbets.org.
2. “Why do doctors choose a $2,000 cure when a $50 one is just as good?” by Andrew Lam, Washington Post, Dec. 10, 2015.
3. “Drug Goes From $13.50 a Tablet to $750, Overnight” by Andrew Pollack, New York Times, Sept. 20, 2015.
4. “How an $84,000 drug got its price: ‘Let’s hold our position … whatever the headlines’ ” by Carolyn Y. Johnson and Brady Dennis, Washington Post, Dec. 1, 2015.
5. JAMA Pediatr. Published online, 2015 Nov 23. doi:10.1001/jamapediatrics.2015.3267.
The 3-month-old infant presents to the emergency department with a fever of 101° F. The emergency physician decides the infant looks ill enough to warrant some investigation. A urinalysis indicates a urinary tract infection. I am consulted to complete the admission to the hospital. The question arises, “Is a lumbar puncture indicated to rule out meningitis?”
I’ve been down this pathway many times. For years I have relied on a meta-analysis which corrected the bias of an old article from 1972.1 Multiple studies in the 2000-2010 time frame have shown that the risk of concurrent meningitis in a young infant with a UTI is vanishingly small. It is much less than 2%, with many studies finding 0%. So on a typical day, my answer is no tap if there is no clinical suggestion of meningitis.
Hospital medicine has recently focused on reducing overdiagnosis and overtreatment. When you only occasionally admit patients to the hospital, untoward events appear random and uncommon. When you work there day in and day out, you appreciate that all medical interventions have risks and costs.
A recent editorial raised the question of stewardship in medicine.2 It asked why physicians would choose a very expensive drug when there is little evidence of its superiority over a much cheaper predecessor. Physicians, whose actions influence a $3 trillion industry, have not embraced stewardship as a major component of their professional responsibilities. The physician does have a fiduciary duty toward the patient. The physician recommends the best care possible to achieve the patient’s goals of care. Dentistry is distinctly different in this regard. Dentists often have several ways of repairing decayed teeth. Various types of fillings are available. Gold fillings are more expensive. Newer implants are several times more expensive than crowns. Dentists routinely adjust their treatment plan based on what the patient can afford.
While most other industries have market competition and profitability as incentives to avoid extravagance, U.S. health care seems unbridled by fiscal responsibility. The news that a small pharmaceutical company had raised the price of an old generic antibiotic by 5000%3 exposed the irrationality and capriciousness4 of the pricing of medications in the United States. Many politicians decried the behavior but to little effect. Most consumer products, especially computers, become more powerful and cheaper with each decade. Health care does not follow this pattern
There are many factors that influence physician behavior. Concerns about malpractice may bias physicians toward expensive overtreatment. Modern medical research is usually published expounding on the benefits of a new technology over a previous therapy without any acknowledgment that the newer and more expensive treatment may have a downside. This biases people to use the latest and greatest treatment even though it may have only demonstrated noninferiority in its trials.
I try to use evidence-based medicine when it is available. In the clinical case described earlier, I indicate to the emergency doctor that unless there is a clinical impression of coexisting meningitis, the lumbar puncture is not indicated. I cite the meta-analysis as I have many times before. But this night is different. I am simultaneously admitting a teenager whose gastrostomy tube had become dislodged and couldn’t be replaced. This neurologically devastated child had had meningitis as an infant. He is a stark reminder of the consequences of a missed diagnosis.
The parents of that child have provided him wonderful care. His skin is in excellent condition. His moderate contractures are testimony to dedicated stretching regimens at home. It is evident that the parents love the child as he is. But I am sure they would give anything to have avoided this scenario and to reverse the consequences of that meningitis. And so, the best evidence we have, that the risk of meningitis in an infant is low, is not as reassuring to me on this night. At 3 a.m., the juxtaposition of the two patients is unsettling. Is the risk low enough? Would that new test5, serum procalcitonin, help me to make a better decision? How certain must I be that an intervention is unnecessary?
Health care policy, economics, and practice guidelines can be debated with detached objectivity around a conference table in the middle of the day. The trepidation in an emergency room at 3 a.m. is different. This is my patient. I am his doctor. That is the heart of medical ethics.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
References
1. “How common is co-existing meningitis in infants with urinary tract infection?” on Bestbets.org.
2. “Why do doctors choose a $2,000 cure when a $50 one is just as good?” by Andrew Lam, Washington Post, Dec. 10, 2015.
3. “Drug Goes From $13.50 a Tablet to $750, Overnight” by Andrew Pollack, New York Times, Sept. 20, 2015.
4. “How an $84,000 drug got its price: ‘Let’s hold our position … whatever the headlines’ ” by Carolyn Y. Johnson and Brady Dennis, Washington Post, Dec. 1, 2015.
5. JAMA Pediatr. Published online, 2015 Nov 23. doi:10.1001/jamapediatrics.2015.3267.
Mental health care is ‘Code Black’
The initial explanation for why the teenager needed to be admitted seemed very flimsy to me. Finally, the office pediatrician came clean. The girl is an honor roll student, high achieving but currently overwhelmed by events in her life. She cannot handle being at home, but there is nowhere else for her to go for the weekend. Come Monday morning, the primary care physician (PCP) has arranged for her acceptance into a local mental health facility where she could get the care she needs. The prognosis was excellent. Her entire future could be markedly improved with just a little help getting through these current troubles. I thought about the patient down the hall. My partner had admitted her 2 days ago for acute-on-chronic abdominal pain, shortly after her third normal CT scan in 6 months. I strongly doubted that that patient had any more business being in a hospital than this latest admission – except, of course, for all the profit the hospital was making on the imaging. On reflection, I decided the PCP’s request no longer seemed so out of place.
The latest emergency department drama on TV has a tagline, “In the ER when there are more patients than resources, it’s called Code Black.” It contains scenes of mopping up bloody floors in the trauma bay. I’ve worked in an ED that was a major portal into a nearby pediatric mental health facility. The major traumas I cared for didn’t bleed from their life-threatening emotional wounds. Multiple times per week, children from across the city were brought in for evaluation. A few needed a toxicology work-up for ingestions. A few more needed some glue or sutures for very superficial self-inflicted forearm lacerations. Mostly I provided a medical screening before getting those teenagers moved as quickly as possible to a team of specialists who could help them. In some parts of this country that can take days.
On Oct. 5, 2015, California’s governor signed a state law permitting physician-assisted suicide. It is now the fifth state allowing that option. The pros and cons have been endlessly debated by ethicists. A brief Google search can find the philosophical arguments. I recommend a June 22, 2015, New Yorker article entitled, “The Death Treatment” by Rachel Aviv to provide a broad narrative perspective. Oregon’s Death With Dignity Act was passed 20 years ago, so it provides some scientific data. There are now 100 deaths per year under that Oregon act. The state also has 700 suicides yearly. So the leading method of suicide in Oregon, by a wide margin, continues to be used by people who are not terminally ill. That was the method of choice recently for my cousin. There was nothing dignified about it. My favorite actor, Robin Williams, in the movie “World’s Greatest Dad,” had the line, “If you’re that depressed, reach out to someone, and remember suicide is a permanent solution to temporary problems.” Five years later he took his own life.
I do enjoy debating the nuances of physician-assisted suicide with other ethicists, but I don’t confuse those academic exercises with addressing the real world problem of endemic suicide. Nationwide, there are 41,000 suicides each year, with about 5,000 in the 15- to 24-year age group. In comparison, 10,000 children annually will get cancer, but only 1,250 children will die of it. There will be about 900 pediatric recipients of lifesaving heart or liver transplants. With all this wealth, knowledge, and technology, the United States should be able to provide better treatment of mental illness. Parity of mental health services became law under President Clinton in 1996, repeated as law under President Bush in 2008, and affirmed again under President Obama. But those political promises have yet to bear fruit in real life. The system remains overloaded. For the sake of the children and young adults, pediatricians must promote expansion of mental health services.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest.
The initial explanation for why the teenager needed to be admitted seemed very flimsy to me. Finally, the office pediatrician came clean. The girl is an honor roll student, high achieving but currently overwhelmed by events in her life. She cannot handle being at home, but there is nowhere else for her to go for the weekend. Come Monday morning, the primary care physician (PCP) has arranged for her acceptance into a local mental health facility where she could get the care she needs. The prognosis was excellent. Her entire future could be markedly improved with just a little help getting through these current troubles. I thought about the patient down the hall. My partner had admitted her 2 days ago for acute-on-chronic abdominal pain, shortly after her third normal CT scan in 6 months. I strongly doubted that that patient had any more business being in a hospital than this latest admission – except, of course, for all the profit the hospital was making on the imaging. On reflection, I decided the PCP’s request no longer seemed so out of place.
The latest emergency department drama on TV has a tagline, “In the ER when there are more patients than resources, it’s called Code Black.” It contains scenes of mopping up bloody floors in the trauma bay. I’ve worked in an ED that was a major portal into a nearby pediatric mental health facility. The major traumas I cared for didn’t bleed from their life-threatening emotional wounds. Multiple times per week, children from across the city were brought in for evaluation. A few needed a toxicology work-up for ingestions. A few more needed some glue or sutures for very superficial self-inflicted forearm lacerations. Mostly I provided a medical screening before getting those teenagers moved as quickly as possible to a team of specialists who could help them. In some parts of this country that can take days.
On Oct. 5, 2015, California’s governor signed a state law permitting physician-assisted suicide. It is now the fifth state allowing that option. The pros and cons have been endlessly debated by ethicists. A brief Google search can find the philosophical arguments. I recommend a June 22, 2015, New Yorker article entitled, “The Death Treatment” by Rachel Aviv to provide a broad narrative perspective. Oregon’s Death With Dignity Act was passed 20 years ago, so it provides some scientific data. There are now 100 deaths per year under that Oregon act. The state also has 700 suicides yearly. So the leading method of suicide in Oregon, by a wide margin, continues to be used by people who are not terminally ill. That was the method of choice recently for my cousin. There was nothing dignified about it. My favorite actor, Robin Williams, in the movie “World’s Greatest Dad,” had the line, “If you’re that depressed, reach out to someone, and remember suicide is a permanent solution to temporary problems.” Five years later he took his own life.
I do enjoy debating the nuances of physician-assisted suicide with other ethicists, but I don’t confuse those academic exercises with addressing the real world problem of endemic suicide. Nationwide, there are 41,000 suicides each year, with about 5,000 in the 15- to 24-year age group. In comparison, 10,000 children annually will get cancer, but only 1,250 children will die of it. There will be about 900 pediatric recipients of lifesaving heart or liver transplants. With all this wealth, knowledge, and technology, the United States should be able to provide better treatment of mental illness. Parity of mental health services became law under President Clinton in 1996, repeated as law under President Bush in 2008, and affirmed again under President Obama. But those political promises have yet to bear fruit in real life. The system remains overloaded. For the sake of the children and young adults, pediatricians must promote expansion of mental health services.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest.
The initial explanation for why the teenager needed to be admitted seemed very flimsy to me. Finally, the office pediatrician came clean. The girl is an honor roll student, high achieving but currently overwhelmed by events in her life. She cannot handle being at home, but there is nowhere else for her to go for the weekend. Come Monday morning, the primary care physician (PCP) has arranged for her acceptance into a local mental health facility where she could get the care she needs. The prognosis was excellent. Her entire future could be markedly improved with just a little help getting through these current troubles. I thought about the patient down the hall. My partner had admitted her 2 days ago for acute-on-chronic abdominal pain, shortly after her third normal CT scan in 6 months. I strongly doubted that that patient had any more business being in a hospital than this latest admission – except, of course, for all the profit the hospital was making on the imaging. On reflection, I decided the PCP’s request no longer seemed so out of place.
The latest emergency department drama on TV has a tagline, “In the ER when there are more patients than resources, it’s called Code Black.” It contains scenes of mopping up bloody floors in the trauma bay. I’ve worked in an ED that was a major portal into a nearby pediatric mental health facility. The major traumas I cared for didn’t bleed from their life-threatening emotional wounds. Multiple times per week, children from across the city were brought in for evaluation. A few needed a toxicology work-up for ingestions. A few more needed some glue or sutures for very superficial self-inflicted forearm lacerations. Mostly I provided a medical screening before getting those teenagers moved as quickly as possible to a team of specialists who could help them. In some parts of this country that can take days.
On Oct. 5, 2015, California’s governor signed a state law permitting physician-assisted suicide. It is now the fifth state allowing that option. The pros and cons have been endlessly debated by ethicists. A brief Google search can find the philosophical arguments. I recommend a June 22, 2015, New Yorker article entitled, “The Death Treatment” by Rachel Aviv to provide a broad narrative perspective. Oregon’s Death With Dignity Act was passed 20 years ago, so it provides some scientific data. There are now 100 deaths per year under that Oregon act. The state also has 700 suicides yearly. So the leading method of suicide in Oregon, by a wide margin, continues to be used by people who are not terminally ill. That was the method of choice recently for my cousin. There was nothing dignified about it. My favorite actor, Robin Williams, in the movie “World’s Greatest Dad,” had the line, “If you’re that depressed, reach out to someone, and remember suicide is a permanent solution to temporary problems.” Five years later he took his own life.
I do enjoy debating the nuances of physician-assisted suicide with other ethicists, but I don’t confuse those academic exercises with addressing the real world problem of endemic suicide. Nationwide, there are 41,000 suicides each year, with about 5,000 in the 15- to 24-year age group. In comparison, 10,000 children annually will get cancer, but only 1,250 children will die of it. There will be about 900 pediatric recipients of lifesaving heart or liver transplants. With all this wealth, knowledge, and technology, the United States should be able to provide better treatment of mental illness. Parity of mental health services became law under President Clinton in 1996, repeated as law under President Bush in 2008, and affirmed again under President Obama. But those political promises have yet to bear fruit in real life. The system remains overloaded. For the sake of the children and young adults, pediatricians must promote expansion of mental health services.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest.
The modern physician-communicator
Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.
Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.
Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).
Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.
This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.
Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com. Dr. Powell said he had no relevant financial disclosures.
Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.
Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.
Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).
Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.
This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.
Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com. Dr. Powell said he had no relevant financial disclosures.
Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.
Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.
Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).
Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.
This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.
Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com. Dr. Powell said he had no relevant financial disclosures.
Perfect is the enemy of good
Urban legends never seem to die. They haunt those who chase the truth because most legends have a kernel of truth. Reflux nephropathy is one of those legends.
In the 1970s, neurosurgeons began treating children with spina bifida rather than allowing them to die shortly after birth. As these children entered their second and third decade of life, episodes of renal failure were noted. The reflux and recurring urinary tract infections (UTIs) from neurogenic bladders damaged kidneys. Self-catheter programs were invented and were effective. Surgical correction of anatomic urinary obstructions and severe reflux yielded similar benefits. By the 1990s, this paradigm had been extrapolated to all children with vesicoureteral reflux (VUR) and codified in the 1999 practice parameter. The unproven hope was that aggressive antibiotic prophylaxis to protect young, growing kidneys from infections would reduce the incidence of renal failure and hypertension in adults.
This is a common methodology for quality improvement at a Mortality and Morbidity conference. A problem is identified. A solution is developed to prevent the bad outcome. The solution is implemented without fully proving that the obvious, customized intervention truly works. No one ever assesses whether the remedy causes more mischief than benefit.
VUR has a pyramid shaped spectrum. Few children have the severe grade V reflux which responds to surgical intervention. At the base of the pyramid are a much larger group of children with mild reflux that usually resolves spontaneously by age 5 years. This pyramid is a setup for overdiagnosis and overtreatment of mild disease. Pediatricians soon recognized that the small portion of the 1999 practice parameter addressing reflux nephropathy was overly aggressive and based on unsound science. However, that same lack of clear evidence delayed creating a new consensus until 2011.
The recent efforts to prove the benefit of prophylaxis used exemplary evidence-based medicine. The RIVUR study over 4 years assessed 10,000 children in a multicenter study involving 19 locations. It enrolled 600 children in a prospective, double-blind, randomized, controlled trial with a placebo control. It followed the children for 2 years. Even by modern standards, this was a huge, prolonged and well-designed trial. It did demonstrate a benefit. About 20% of children on placebo had a recurrent UTI in that 2-year time frame. There was a 50% reduction in the number of UTIs in the children treated with antibiotic prophylaxis. Phrased that way, it was a success. But the numbers can be spun differently. The article duly noted a number needed to treat of eight. Eight children treated for 2 years at 365 days per year and one dose per day, means that 6,000 doses of antibiotics were necessary to prevent one UTI. There was no demonstrated benefit in renal scarring, renal failure, or other long-term outcomes. There was a downside. The rate of antibiotic-resistant organisms in the breakthrough UTIs tripled from 19% of the placebo group to 63% of the prophylaxis group. As large as this study was, it wasn’t able to measure the rate of other known adverse outcomes, such as Stevens-Johnson syndrome from the use of sulfa medications or the impact on resistant infections elsewhere in the body.
With the 2011 practice parameter, pediatricians became less aggressive at working up first UTIs. Urologists disagreed. The May 2015 issue of AAP News had a full page article by Dr. Saul Greenfield, who is the chairperson-elect for the Executive Committee of the American Academy of Pediatrics Section on Urology, a urologist in Buffalo, N.Y., and one of the RIVUR trial’s investigators (AAP News 2015;36:13). He rehashed the RIVUR study results emphasizing the reduction in UTIs, but offered no quantitative assessment of the risks, costs, and harms of prophylaxis.
A June 2015 article in Pediatrics gives the results of the CUTIE study, which ran in parallel with the RIVUR study (Pediatrics 2015 [doi:10.1542/peds.2015-0409]). The conclusions: “VUR and BBD [bladder and bowel dysfunction] are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.”
The article concludes with, “Therefore, clinicians must help families decide whether the benefits of prophylaxis outweigh the risks and inconvenience. … Additional research is needed to validate the risk factors and profiles that we identified.”
But six pages of discussing renal scarring (which is only a proxy for a small risk of future renal failure or hypertension), followed by a couple paragraphs, without numbers, about the risks of prophylaxis, does not provide the balanced presentation clinicians need to help families make wise decisions. In the new era of Choosing Wisely, scientific articles making clinical recommendations should not be published without an accompanying risk-benefit analysis, either in the article or in an editorial. The maxim in surgery, channeling Voltaire, is that “perfect is the enemy of good.”
There is mounting evidence that giving any antibiotics to young infants is harmful. Even 2 days of antibiotics before 1 month of age leads to measurable changes in the gut microbiota 6 months later. Antibiotics in infancy are associated with obesity at 24 months and at 48 months of age. All medical treatments introduce a substantial risk of harm. As Shakespeare wrote 400 years ago, “Striving to better, oft we mar what’s well.” I don’t doubt the conclusion that prophylaxis reduces UTIs, but giving 6,000 doses to prevent one UTI?! Even Kaley Cuoco can’t sell that.
Ultimately, this choice is not up to the hospitalist, the emergency department doctor, or the urologist. The decision belongs to the parents guided by a primary care doctor they trust. Our professional duty, ethically and legally, is to communicate the risks and benefits to the parents in a manner which they can understand and to provide them the support and counseling necessary to make a wise choice for their child. By focusing on the child and that duty, medical professionals can defuse any clashes of egos, departmental power struggles, or autocratic hierarchy that might interfere. Doctors educate and recommend, but the parent decides what is best for his or her child.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
Urban legends never seem to die. They haunt those who chase the truth because most legends have a kernel of truth. Reflux nephropathy is one of those legends.
In the 1970s, neurosurgeons began treating children with spina bifida rather than allowing them to die shortly after birth. As these children entered their second and third decade of life, episodes of renal failure were noted. The reflux and recurring urinary tract infections (UTIs) from neurogenic bladders damaged kidneys. Self-catheter programs were invented and were effective. Surgical correction of anatomic urinary obstructions and severe reflux yielded similar benefits. By the 1990s, this paradigm had been extrapolated to all children with vesicoureteral reflux (VUR) and codified in the 1999 practice parameter. The unproven hope was that aggressive antibiotic prophylaxis to protect young, growing kidneys from infections would reduce the incidence of renal failure and hypertension in adults.
This is a common methodology for quality improvement at a Mortality and Morbidity conference. A problem is identified. A solution is developed to prevent the bad outcome. The solution is implemented without fully proving that the obvious, customized intervention truly works. No one ever assesses whether the remedy causes more mischief than benefit.
VUR has a pyramid shaped spectrum. Few children have the severe grade V reflux which responds to surgical intervention. At the base of the pyramid are a much larger group of children with mild reflux that usually resolves spontaneously by age 5 years. This pyramid is a setup for overdiagnosis and overtreatment of mild disease. Pediatricians soon recognized that the small portion of the 1999 practice parameter addressing reflux nephropathy was overly aggressive and based on unsound science. However, that same lack of clear evidence delayed creating a new consensus until 2011.
The recent efforts to prove the benefit of prophylaxis used exemplary evidence-based medicine. The RIVUR study over 4 years assessed 10,000 children in a multicenter study involving 19 locations. It enrolled 600 children in a prospective, double-blind, randomized, controlled trial with a placebo control. It followed the children for 2 years. Even by modern standards, this was a huge, prolonged and well-designed trial. It did demonstrate a benefit. About 20% of children on placebo had a recurrent UTI in that 2-year time frame. There was a 50% reduction in the number of UTIs in the children treated with antibiotic prophylaxis. Phrased that way, it was a success. But the numbers can be spun differently. The article duly noted a number needed to treat of eight. Eight children treated for 2 years at 365 days per year and one dose per day, means that 6,000 doses of antibiotics were necessary to prevent one UTI. There was no demonstrated benefit in renal scarring, renal failure, or other long-term outcomes. There was a downside. The rate of antibiotic-resistant organisms in the breakthrough UTIs tripled from 19% of the placebo group to 63% of the prophylaxis group. As large as this study was, it wasn’t able to measure the rate of other known adverse outcomes, such as Stevens-Johnson syndrome from the use of sulfa medications or the impact on resistant infections elsewhere in the body.
With the 2011 practice parameter, pediatricians became less aggressive at working up first UTIs. Urologists disagreed. The May 2015 issue of AAP News had a full page article by Dr. Saul Greenfield, who is the chairperson-elect for the Executive Committee of the American Academy of Pediatrics Section on Urology, a urologist in Buffalo, N.Y., and one of the RIVUR trial’s investigators (AAP News 2015;36:13). He rehashed the RIVUR study results emphasizing the reduction in UTIs, but offered no quantitative assessment of the risks, costs, and harms of prophylaxis.
A June 2015 article in Pediatrics gives the results of the CUTIE study, which ran in parallel with the RIVUR study (Pediatrics 2015 [doi:10.1542/peds.2015-0409]). The conclusions: “VUR and BBD [bladder and bowel dysfunction] are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.”
The article concludes with, “Therefore, clinicians must help families decide whether the benefits of prophylaxis outweigh the risks and inconvenience. … Additional research is needed to validate the risk factors and profiles that we identified.”
But six pages of discussing renal scarring (which is only a proxy for a small risk of future renal failure or hypertension), followed by a couple paragraphs, without numbers, about the risks of prophylaxis, does not provide the balanced presentation clinicians need to help families make wise decisions. In the new era of Choosing Wisely, scientific articles making clinical recommendations should not be published without an accompanying risk-benefit analysis, either in the article or in an editorial. The maxim in surgery, channeling Voltaire, is that “perfect is the enemy of good.”
There is mounting evidence that giving any antibiotics to young infants is harmful. Even 2 days of antibiotics before 1 month of age leads to measurable changes in the gut microbiota 6 months later. Antibiotics in infancy are associated with obesity at 24 months and at 48 months of age. All medical treatments introduce a substantial risk of harm. As Shakespeare wrote 400 years ago, “Striving to better, oft we mar what’s well.” I don’t doubt the conclusion that prophylaxis reduces UTIs, but giving 6,000 doses to prevent one UTI?! Even Kaley Cuoco can’t sell that.
Ultimately, this choice is not up to the hospitalist, the emergency department doctor, or the urologist. The decision belongs to the parents guided by a primary care doctor they trust. Our professional duty, ethically and legally, is to communicate the risks and benefits to the parents in a manner which they can understand and to provide them the support and counseling necessary to make a wise choice for their child. By focusing on the child and that duty, medical professionals can defuse any clashes of egos, departmental power struggles, or autocratic hierarchy that might interfere. Doctors educate and recommend, but the parent decides what is best for his or her child.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
Urban legends never seem to die. They haunt those who chase the truth because most legends have a kernel of truth. Reflux nephropathy is one of those legends.
In the 1970s, neurosurgeons began treating children with spina bifida rather than allowing them to die shortly after birth. As these children entered their second and third decade of life, episodes of renal failure were noted. The reflux and recurring urinary tract infections (UTIs) from neurogenic bladders damaged kidneys. Self-catheter programs were invented and were effective. Surgical correction of anatomic urinary obstructions and severe reflux yielded similar benefits. By the 1990s, this paradigm had been extrapolated to all children with vesicoureteral reflux (VUR) and codified in the 1999 practice parameter. The unproven hope was that aggressive antibiotic prophylaxis to protect young, growing kidneys from infections would reduce the incidence of renal failure and hypertension in adults.
This is a common methodology for quality improvement at a Mortality and Morbidity conference. A problem is identified. A solution is developed to prevent the bad outcome. The solution is implemented without fully proving that the obvious, customized intervention truly works. No one ever assesses whether the remedy causes more mischief than benefit.
VUR has a pyramid shaped spectrum. Few children have the severe grade V reflux which responds to surgical intervention. At the base of the pyramid are a much larger group of children with mild reflux that usually resolves spontaneously by age 5 years. This pyramid is a setup for overdiagnosis and overtreatment of mild disease. Pediatricians soon recognized that the small portion of the 1999 practice parameter addressing reflux nephropathy was overly aggressive and based on unsound science. However, that same lack of clear evidence delayed creating a new consensus until 2011.
The recent efforts to prove the benefit of prophylaxis used exemplary evidence-based medicine. The RIVUR study over 4 years assessed 10,000 children in a multicenter study involving 19 locations. It enrolled 600 children in a prospective, double-blind, randomized, controlled trial with a placebo control. It followed the children for 2 years. Even by modern standards, this was a huge, prolonged and well-designed trial. It did demonstrate a benefit. About 20% of children on placebo had a recurrent UTI in that 2-year time frame. There was a 50% reduction in the number of UTIs in the children treated with antibiotic prophylaxis. Phrased that way, it was a success. But the numbers can be spun differently. The article duly noted a number needed to treat of eight. Eight children treated for 2 years at 365 days per year and one dose per day, means that 6,000 doses of antibiotics were necessary to prevent one UTI. There was no demonstrated benefit in renal scarring, renal failure, or other long-term outcomes. There was a downside. The rate of antibiotic-resistant organisms in the breakthrough UTIs tripled from 19% of the placebo group to 63% of the prophylaxis group. As large as this study was, it wasn’t able to measure the rate of other known adverse outcomes, such as Stevens-Johnson syndrome from the use of sulfa medications or the impact on resistant infections elsewhere in the body.
With the 2011 practice parameter, pediatricians became less aggressive at working up first UTIs. Urologists disagreed. The May 2015 issue of AAP News had a full page article by Dr. Saul Greenfield, who is the chairperson-elect for the Executive Committee of the American Academy of Pediatrics Section on Urology, a urologist in Buffalo, N.Y., and one of the RIVUR trial’s investigators (AAP News 2015;36:13). He rehashed the RIVUR study results emphasizing the reduction in UTIs, but offered no quantitative assessment of the risks, costs, and harms of prophylaxis.
A June 2015 article in Pediatrics gives the results of the CUTIE study, which ran in parallel with the RIVUR study (Pediatrics 2015 [doi:10.1542/peds.2015-0409]). The conclusions: “VUR and BBD [bladder and bowel dysfunction] are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.”
The article concludes with, “Therefore, clinicians must help families decide whether the benefits of prophylaxis outweigh the risks and inconvenience. … Additional research is needed to validate the risk factors and profiles that we identified.”
But six pages of discussing renal scarring (which is only a proxy for a small risk of future renal failure or hypertension), followed by a couple paragraphs, without numbers, about the risks of prophylaxis, does not provide the balanced presentation clinicians need to help families make wise decisions. In the new era of Choosing Wisely, scientific articles making clinical recommendations should not be published without an accompanying risk-benefit analysis, either in the article or in an editorial. The maxim in surgery, channeling Voltaire, is that “perfect is the enemy of good.”
There is mounting evidence that giving any antibiotics to young infants is harmful. Even 2 days of antibiotics before 1 month of age leads to measurable changes in the gut microbiota 6 months later. Antibiotics in infancy are associated with obesity at 24 months and at 48 months of age. All medical treatments introduce a substantial risk of harm. As Shakespeare wrote 400 years ago, “Striving to better, oft we mar what’s well.” I don’t doubt the conclusion that prophylaxis reduces UTIs, but giving 6,000 doses to prevent one UTI?! Even Kaley Cuoco can’t sell that.
Ultimately, this choice is not up to the hospitalist, the emergency department doctor, or the urologist. The decision belongs to the parents guided by a primary care doctor they trust. Our professional duty, ethically and legally, is to communicate the risks and benefits to the parents in a manner which they can understand and to provide them the support and counseling necessary to make a wise choice for their child. By focusing on the child and that duty, medical professionals can defuse any clashes of egos, departmental power struggles, or autocratic hierarchy that might interfere. Doctors educate and recommend, but the parent decides what is best for his or her child.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.
Paging Dr. Google
The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.
Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.
The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.
Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.
If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.
Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?
The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.
I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at pdnews@frontlinemedcom.com.
The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.
Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.
The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.
Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.
If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.
Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?
The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.
I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at pdnews@frontlinemedcom.com.
The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.
Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.
The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.
Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.
If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.
Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?
The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.
I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at pdnews@frontlinemedcom.com.
Avoiding disillusionment
The holiday season, despite the hustle and bustle, can be a time of reflection. Thanksgiving is a time to reflect on what you have. The secular version of Christmas is a deep plunge into materialism and getting the things you desire. Then come those New Year’s resolutions in which you swear off material things and promise yourself you will become the person you have always wanted to be.
For those in academic settings educating the next cohort of physicians, this time of year has its own rituals. Undergraduate and medical school applications are being reviewed. Medical students are interviewing for residencies. Match day for residents seeking subspecialty fellowships occurs in mid-December. The other residents are starting to interview for real jobs. Overall, a vast undertaking occurs in which talents and aspirations are matched with finite and practical opportunities.
My goal is to advocate for the health of children, so I am concerned about how well pediatrics attracts the best and brightest minds. The best training programs in the world are still going to produce mediocre doctors if we start with mediocre talent. The stakes in recruiting talent are huge. The Washington Post has been running a series on the disappearance of the middle class. Some articles have lamented that the finance sector has recently siphoned off the best and brightest minds to make money by pushing money, rather than creating new technology, products, and jobs (“A black hole for our best and brightest,” by Jim Tankersley on Dec. 14, 2014). My second concern is nourishing the ideals and aspirations of those physician seedlings. Few people keep all their New Year’s resolutions for the entire year, but even partial credit can be important progress in a balanced life.
First, we need to attract people to science. There is a recognized shortage of high school students going into STEM fields (science, technology, engineering, and math). Various programs have been created to attract high school students, and particularly women, to those fields (“Women flocking to statistics, the newly hot, high-tech field of data science,” by Brigid Schulte, the Washington Post, Dec. 19, 2014). This then needs to be reinforced in college. For instance, the analysis of big data in health care is a burgeoning field. We need statisticians who can do the work.
Then we need to attract people to medicine. I’ve been in a few conversations recently about a book titled “Doctored: The Disillusionment of the American Physician,” by Dr. Sandeep Jauhar. I haven’t read more than a few excerpts from the book. An abbreviated version is the author’s essay, “Why Doctors Are Sick of Their Profession,” in the Wall Street Journal (Aug. 29, 2014).
There were enough inaccuracies in that article to dissuade me from reading further, but your mileage may differ. There are data to both support and refute most of his assertions. I believe he is correct that there have been some Faustian bargains made by the past two generations of doctors. Medicine welcomed the improved revenues from Medicare and Medicaid coverage. Those programs improved access, justice, health outcomes, and especially doctors’ incomes, but at a steep price to society. The Golden Goose Dr. Jauhar cited was indeed killed. The following generation of doctors has had to deal with managed care, preapprovals, and denials of payment, along with other cost controls. It was irrational to think that all that money from the government to physicians was going to flow indefinitely without strings. In a related development, the resulting paperwork has crushed solo office practice. Rather than being entrepreneurs, recently boarded pediatricians are trending toward larger group practices and salaried positions. So that affects the degree of independence in a medical career.
In pediatrics, physicians invest considerable time to open career paths into subspecialty areas that interest them, even if the income and lifestyle aren’t better and don’t justify the time and expense of further training. Pediatric hospital medicine is progressing toward becoming a boarded subspecialty with 2-year fellowships. Will that attract the best and brightest of the residents?
Continuing medical education is needed to maintain a knowledge base and a skill set. I assert there also needs to be continuing examination and reinforcement of one’s ideals and life goals. As a pediatrician, I am biased toward believing that maintaining a recommended daily allowance of that activity outperforms making New Year’s resolutions. We all know that crash diets rarely work in the long run.
What practical steps can be taken in the pediatrician’s office? Put up posters that encourage STEM education. Ask adolescents about their plans. The health and life expectancy of your patient will be related far more to his or her career choice than to the discovery of the next medicine to treat chronic hepatitis C. Spending just a moment of each adolescent well visit to explore his/her aspirations also may be just the medicine you need to avoid disillusionment. Maybe you will even inspire a bright teenager to become a pediatrician.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine. E-mail him at pdnews@frontlinemedcom.com.
The holiday season, despite the hustle and bustle, can be a time of reflection. Thanksgiving is a time to reflect on what you have. The secular version of Christmas is a deep plunge into materialism and getting the things you desire. Then come those New Year’s resolutions in which you swear off material things and promise yourself you will become the person you have always wanted to be.
For those in academic settings educating the next cohort of physicians, this time of year has its own rituals. Undergraduate and medical school applications are being reviewed. Medical students are interviewing for residencies. Match day for residents seeking subspecialty fellowships occurs in mid-December. The other residents are starting to interview for real jobs. Overall, a vast undertaking occurs in which talents and aspirations are matched with finite and practical opportunities.
My goal is to advocate for the health of children, so I am concerned about how well pediatrics attracts the best and brightest minds. The best training programs in the world are still going to produce mediocre doctors if we start with mediocre talent. The stakes in recruiting talent are huge. The Washington Post has been running a series on the disappearance of the middle class. Some articles have lamented that the finance sector has recently siphoned off the best and brightest minds to make money by pushing money, rather than creating new technology, products, and jobs (“A black hole for our best and brightest,” by Jim Tankersley on Dec. 14, 2014). My second concern is nourishing the ideals and aspirations of those physician seedlings. Few people keep all their New Year’s resolutions for the entire year, but even partial credit can be important progress in a balanced life.
First, we need to attract people to science. There is a recognized shortage of high school students going into STEM fields (science, technology, engineering, and math). Various programs have been created to attract high school students, and particularly women, to those fields (“Women flocking to statistics, the newly hot, high-tech field of data science,” by Brigid Schulte, the Washington Post, Dec. 19, 2014). This then needs to be reinforced in college. For instance, the analysis of big data in health care is a burgeoning field. We need statisticians who can do the work.
Then we need to attract people to medicine. I’ve been in a few conversations recently about a book titled “Doctored: The Disillusionment of the American Physician,” by Dr. Sandeep Jauhar. I haven’t read more than a few excerpts from the book. An abbreviated version is the author’s essay, “Why Doctors Are Sick of Their Profession,” in the Wall Street Journal (Aug. 29, 2014).
There were enough inaccuracies in that article to dissuade me from reading further, but your mileage may differ. There are data to both support and refute most of his assertions. I believe he is correct that there have been some Faustian bargains made by the past two generations of doctors. Medicine welcomed the improved revenues from Medicare and Medicaid coverage. Those programs improved access, justice, health outcomes, and especially doctors’ incomes, but at a steep price to society. The Golden Goose Dr. Jauhar cited was indeed killed. The following generation of doctors has had to deal with managed care, preapprovals, and denials of payment, along with other cost controls. It was irrational to think that all that money from the government to physicians was going to flow indefinitely without strings. In a related development, the resulting paperwork has crushed solo office practice. Rather than being entrepreneurs, recently boarded pediatricians are trending toward larger group practices and salaried positions. So that affects the degree of independence in a medical career.
In pediatrics, physicians invest considerable time to open career paths into subspecialty areas that interest them, even if the income and lifestyle aren’t better and don’t justify the time and expense of further training. Pediatric hospital medicine is progressing toward becoming a boarded subspecialty with 2-year fellowships. Will that attract the best and brightest of the residents?
Continuing medical education is needed to maintain a knowledge base and a skill set. I assert there also needs to be continuing examination and reinforcement of one’s ideals and life goals. As a pediatrician, I am biased toward believing that maintaining a recommended daily allowance of that activity outperforms making New Year’s resolutions. We all know that crash diets rarely work in the long run.
What practical steps can be taken in the pediatrician’s office? Put up posters that encourage STEM education. Ask adolescents about their plans. The health and life expectancy of your patient will be related far more to his or her career choice than to the discovery of the next medicine to treat chronic hepatitis C. Spending just a moment of each adolescent well visit to explore his/her aspirations also may be just the medicine you need to avoid disillusionment. Maybe you will even inspire a bright teenager to become a pediatrician.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine. E-mail him at pdnews@frontlinemedcom.com.
The holiday season, despite the hustle and bustle, can be a time of reflection. Thanksgiving is a time to reflect on what you have. The secular version of Christmas is a deep plunge into materialism and getting the things you desire. Then come those New Year’s resolutions in which you swear off material things and promise yourself you will become the person you have always wanted to be.
For those in academic settings educating the next cohort of physicians, this time of year has its own rituals. Undergraduate and medical school applications are being reviewed. Medical students are interviewing for residencies. Match day for residents seeking subspecialty fellowships occurs in mid-December. The other residents are starting to interview for real jobs. Overall, a vast undertaking occurs in which talents and aspirations are matched with finite and practical opportunities.
My goal is to advocate for the health of children, so I am concerned about how well pediatrics attracts the best and brightest minds. The best training programs in the world are still going to produce mediocre doctors if we start with mediocre talent. The stakes in recruiting talent are huge. The Washington Post has been running a series on the disappearance of the middle class. Some articles have lamented that the finance sector has recently siphoned off the best and brightest minds to make money by pushing money, rather than creating new technology, products, and jobs (“A black hole for our best and brightest,” by Jim Tankersley on Dec. 14, 2014). My second concern is nourishing the ideals and aspirations of those physician seedlings. Few people keep all their New Year’s resolutions for the entire year, but even partial credit can be important progress in a balanced life.
First, we need to attract people to science. There is a recognized shortage of high school students going into STEM fields (science, technology, engineering, and math). Various programs have been created to attract high school students, and particularly women, to those fields (“Women flocking to statistics, the newly hot, high-tech field of data science,” by Brigid Schulte, the Washington Post, Dec. 19, 2014). This then needs to be reinforced in college. For instance, the analysis of big data in health care is a burgeoning field. We need statisticians who can do the work.
Then we need to attract people to medicine. I’ve been in a few conversations recently about a book titled “Doctored: The Disillusionment of the American Physician,” by Dr. Sandeep Jauhar. I haven’t read more than a few excerpts from the book. An abbreviated version is the author’s essay, “Why Doctors Are Sick of Their Profession,” in the Wall Street Journal (Aug. 29, 2014).
There were enough inaccuracies in that article to dissuade me from reading further, but your mileage may differ. There are data to both support and refute most of his assertions. I believe he is correct that there have been some Faustian bargains made by the past two generations of doctors. Medicine welcomed the improved revenues from Medicare and Medicaid coverage. Those programs improved access, justice, health outcomes, and especially doctors’ incomes, but at a steep price to society. The Golden Goose Dr. Jauhar cited was indeed killed. The following generation of doctors has had to deal with managed care, preapprovals, and denials of payment, along with other cost controls. It was irrational to think that all that money from the government to physicians was going to flow indefinitely without strings. In a related development, the resulting paperwork has crushed solo office practice. Rather than being entrepreneurs, recently boarded pediatricians are trending toward larger group practices and salaried positions. So that affects the degree of independence in a medical career.
In pediatrics, physicians invest considerable time to open career paths into subspecialty areas that interest them, even if the income and lifestyle aren’t better and don’t justify the time and expense of further training. Pediatric hospital medicine is progressing toward becoming a boarded subspecialty with 2-year fellowships. Will that attract the best and brightest of the residents?
Continuing medical education is needed to maintain a knowledge base and a skill set. I assert there also needs to be continuing examination and reinforcement of one’s ideals and life goals. As a pediatrician, I am biased toward believing that maintaining a recommended daily allowance of that activity outperforms making New Year’s resolutions. We all know that crash diets rarely work in the long run.
What practical steps can be taken in the pediatrician’s office? Put up posters that encourage STEM education. Ask adolescents about their plans. The health and life expectancy of your patient will be related far more to his or her career choice than to the discovery of the next medicine to treat chronic hepatitis C. Spending just a moment of each adolescent well visit to explore his/her aspirations also may be just the medicine you need to avoid disillusionment. Maybe you will even inspire a bright teenager to become a pediatrician.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine. E-mail him at pdnews@frontlinemedcom.com.
For whom the Ebola tolls
Infectious diseases have been common topics in the news these past 2 months. Enterovirus EV-D68 and Ebola were the focus of sessions and plenary talks at this year’s American Academy of Pediatrics National Conference and Exposition. The new respiratory syncytial virus prophylaxis guidelines for this winter markedly narrowed the recommended recipient population (Pediatrics 2014;134:415-20). The revision of the 2006 bronchiolitis care guideline was released (Pediatrics 2014 [doi: 10.1542/peds.2014-2742]). And there has been an indictment in an alleged fraud involving HIV vaccine research.
As a moderator of a Listserv for pediatric hospitalists, I am interested in both the content of these discussions and the process by which they occur. Pediatric hospitalists could grouse a bit about the Centers for Disease Control and Prevention (CDC) being a few days slow in disseminating information about the EV-D68 epidemic, but we had no reason to doubt the veracity of that information. Our Listserv had posts from pediatric hospitalists in various cities. We discussed the utility of diagnostic tests; the treatment options and their effectiveness compared with other cases of bronchiolitis; and the impact on emergency department and inpatient census. When the virus 2 weeks later was tenuously associated with a rare paralytic syndrome, the Listserv activity peaked again.
Public reaction to Ebola seems to be at the other extreme. The contagion to two nurses and exposure of a lab supervisor at a Dallas hospital have expanded to impact hundreds of airline passengers and cruise ship passengers. Governors in New York and New Jersey took actions to increase monitoring at airports and establish quarantines. Now Maine is involved. Those actions did not always agree with the suggestions of the CDC. Between the Department of Veterans Affairs scandal, the CDC mishandling of small pox and anthrax in its labs, Wikileaks, and celebrities dissing vaccines, the general public’s trust in health information provided by the U.S. government must be near an all-time low just when credibility is needed most.
Does this sound familiar? George Santayana said, “Those who cannot remember the past are condemned to repeat it.” AIDS in 1981 was a new, lethal contagious disease without an effective treatment. Five cases of unusual pneumonia reported in 1981 have become a million people living with the infection. There were fear, stigmatization, recriminations, political posturing, and many deaths. In response, patient isolation practices changed dramatically. A massive research program ensued that has failed to find a vaccine or cure for HIV, but has developed an expensive ongoing treatment regimen that controls the disease in most people who can afford it. That has left out most people in Africa.
The United States now has an Ebola czar. Ron Klain has no experience with tropical infectious diseases. He was selected because he knows how things get done in Washington, D.C. I don’t see him becoming another C. Everett Koop, credible and comforting. For that status, the New York Times was impressed with the local version of that official.
“People need to feel like they are being given information, that things aren’t being kept from them, that they are being apprised of what’s known, and that we’re being honest. ...”
“Fear is a powerful thing,” she added, “and it’s often not rational. That’s when reliance on science and fact really has to be our North Star.” –Dr. Mary Travis Bassett, New York City Health Commissioner
On the spectrum between these two experiences with EV-D68 and Ebola lie the battles over respiratory syncytial virus prophylaxis and treatment. At the AAP National Conference and Exposition session discussing the 2014 palivizumab recommendations, there was great attention paid to having speakers from the audience identify any conflicts of interest they might have. The new guideline on caring for infants with bronchiolitis has emphasized the methodology of evidence-based medicine. Both these approaches (conflicts of interest and evidence-based medicine) are recent tools in the quest for truth and credibility.
Jack Nicholson said, “You can’t handle the truth!” Woodward and Bernstein, the investigative reporters of Watergate, recently eulogized their editor Ben Bradlee with “His one unbending principle was the quest for the truth and the necessity of that pursuit.”
I can’t add anything at this time to the search for truth in dealing with Ebola and what sort of quarantine policies should be in place. The credibility problem is in the hands of politicos. The balancing of communal safety and individual rights is in the hands of judges. But whatever choices are made, medical ethics requires that they be implemented with respect and with compassion, which includes WiFi access. That is in the hands of nurses and doctors. So I will close with a quote from a meditation written nearly 400 years ago by John Donne, an English poet and cleric, during his own 3-week battle with a near-fatal illness.
“No man is an island, entire of itself; ... any man’s death diminishes me, ... therefore never send to know for whom the bell tolls; it tolls for thee.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
Infectious diseases have been common topics in the news these past 2 months. Enterovirus EV-D68 and Ebola were the focus of sessions and plenary talks at this year’s American Academy of Pediatrics National Conference and Exposition. The new respiratory syncytial virus prophylaxis guidelines for this winter markedly narrowed the recommended recipient population (Pediatrics 2014;134:415-20). The revision of the 2006 bronchiolitis care guideline was released (Pediatrics 2014 [doi: 10.1542/peds.2014-2742]). And there has been an indictment in an alleged fraud involving HIV vaccine research.
As a moderator of a Listserv for pediatric hospitalists, I am interested in both the content of these discussions and the process by which they occur. Pediatric hospitalists could grouse a bit about the Centers for Disease Control and Prevention (CDC) being a few days slow in disseminating information about the EV-D68 epidemic, but we had no reason to doubt the veracity of that information. Our Listserv had posts from pediatric hospitalists in various cities. We discussed the utility of diagnostic tests; the treatment options and their effectiveness compared with other cases of bronchiolitis; and the impact on emergency department and inpatient census. When the virus 2 weeks later was tenuously associated with a rare paralytic syndrome, the Listserv activity peaked again.
Public reaction to Ebola seems to be at the other extreme. The contagion to two nurses and exposure of a lab supervisor at a Dallas hospital have expanded to impact hundreds of airline passengers and cruise ship passengers. Governors in New York and New Jersey took actions to increase monitoring at airports and establish quarantines. Now Maine is involved. Those actions did not always agree with the suggestions of the CDC. Between the Department of Veterans Affairs scandal, the CDC mishandling of small pox and anthrax in its labs, Wikileaks, and celebrities dissing vaccines, the general public’s trust in health information provided by the U.S. government must be near an all-time low just when credibility is needed most.
Does this sound familiar? George Santayana said, “Those who cannot remember the past are condemned to repeat it.” AIDS in 1981 was a new, lethal contagious disease without an effective treatment. Five cases of unusual pneumonia reported in 1981 have become a million people living with the infection. There were fear, stigmatization, recriminations, political posturing, and many deaths. In response, patient isolation practices changed dramatically. A massive research program ensued that has failed to find a vaccine or cure for HIV, but has developed an expensive ongoing treatment regimen that controls the disease in most people who can afford it. That has left out most people in Africa.
The United States now has an Ebola czar. Ron Klain has no experience with tropical infectious diseases. He was selected because he knows how things get done in Washington, D.C. I don’t see him becoming another C. Everett Koop, credible and comforting. For that status, the New York Times was impressed with the local version of that official.
“People need to feel like they are being given information, that things aren’t being kept from them, that they are being apprised of what’s known, and that we’re being honest. ...”
“Fear is a powerful thing,” she added, “and it’s often not rational. That’s when reliance on science and fact really has to be our North Star.” –Dr. Mary Travis Bassett, New York City Health Commissioner
On the spectrum between these two experiences with EV-D68 and Ebola lie the battles over respiratory syncytial virus prophylaxis and treatment. At the AAP National Conference and Exposition session discussing the 2014 palivizumab recommendations, there was great attention paid to having speakers from the audience identify any conflicts of interest they might have. The new guideline on caring for infants with bronchiolitis has emphasized the methodology of evidence-based medicine. Both these approaches (conflicts of interest and evidence-based medicine) are recent tools in the quest for truth and credibility.
Jack Nicholson said, “You can’t handle the truth!” Woodward and Bernstein, the investigative reporters of Watergate, recently eulogized their editor Ben Bradlee with “His one unbending principle was the quest for the truth and the necessity of that pursuit.”
I can’t add anything at this time to the search for truth in dealing with Ebola and what sort of quarantine policies should be in place. The credibility problem is in the hands of politicos. The balancing of communal safety and individual rights is in the hands of judges. But whatever choices are made, medical ethics requires that they be implemented with respect and with compassion, which includes WiFi access. That is in the hands of nurses and doctors. So I will close with a quote from a meditation written nearly 400 years ago by John Donne, an English poet and cleric, during his own 3-week battle with a near-fatal illness.
“No man is an island, entire of itself; ... any man’s death diminishes me, ... therefore never send to know for whom the bell tolls; it tolls for thee.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
Infectious diseases have been common topics in the news these past 2 months. Enterovirus EV-D68 and Ebola were the focus of sessions and plenary talks at this year’s American Academy of Pediatrics National Conference and Exposition. The new respiratory syncytial virus prophylaxis guidelines for this winter markedly narrowed the recommended recipient population (Pediatrics 2014;134:415-20). The revision of the 2006 bronchiolitis care guideline was released (Pediatrics 2014 [doi: 10.1542/peds.2014-2742]). And there has been an indictment in an alleged fraud involving HIV vaccine research.
As a moderator of a Listserv for pediatric hospitalists, I am interested in both the content of these discussions and the process by which they occur. Pediatric hospitalists could grouse a bit about the Centers for Disease Control and Prevention (CDC) being a few days slow in disseminating information about the EV-D68 epidemic, but we had no reason to doubt the veracity of that information. Our Listserv had posts from pediatric hospitalists in various cities. We discussed the utility of diagnostic tests; the treatment options and their effectiveness compared with other cases of bronchiolitis; and the impact on emergency department and inpatient census. When the virus 2 weeks later was tenuously associated with a rare paralytic syndrome, the Listserv activity peaked again.
Public reaction to Ebola seems to be at the other extreme. The contagion to two nurses and exposure of a lab supervisor at a Dallas hospital have expanded to impact hundreds of airline passengers and cruise ship passengers. Governors in New York and New Jersey took actions to increase monitoring at airports and establish quarantines. Now Maine is involved. Those actions did not always agree with the suggestions of the CDC. Between the Department of Veterans Affairs scandal, the CDC mishandling of small pox and anthrax in its labs, Wikileaks, and celebrities dissing vaccines, the general public’s trust in health information provided by the U.S. government must be near an all-time low just when credibility is needed most.
Does this sound familiar? George Santayana said, “Those who cannot remember the past are condemned to repeat it.” AIDS in 1981 was a new, lethal contagious disease without an effective treatment. Five cases of unusual pneumonia reported in 1981 have become a million people living with the infection. There were fear, stigmatization, recriminations, political posturing, and many deaths. In response, patient isolation practices changed dramatically. A massive research program ensued that has failed to find a vaccine or cure for HIV, but has developed an expensive ongoing treatment regimen that controls the disease in most people who can afford it. That has left out most people in Africa.
The United States now has an Ebola czar. Ron Klain has no experience with tropical infectious diseases. He was selected because he knows how things get done in Washington, D.C. I don’t see him becoming another C. Everett Koop, credible and comforting. For that status, the New York Times was impressed with the local version of that official.
“People need to feel like they are being given information, that things aren’t being kept from them, that they are being apprised of what’s known, and that we’re being honest. ...”
“Fear is a powerful thing,” she added, “and it’s often not rational. That’s when reliance on science and fact really has to be our North Star.” –Dr. Mary Travis Bassett, New York City Health Commissioner
On the spectrum between these two experiences with EV-D68 and Ebola lie the battles over respiratory syncytial virus prophylaxis and treatment. At the AAP National Conference and Exposition session discussing the 2014 palivizumab recommendations, there was great attention paid to having speakers from the audience identify any conflicts of interest they might have. The new guideline on caring for infants with bronchiolitis has emphasized the methodology of evidence-based medicine. Both these approaches (conflicts of interest and evidence-based medicine) are recent tools in the quest for truth and credibility.
Jack Nicholson said, “You can’t handle the truth!” Woodward and Bernstein, the investigative reporters of Watergate, recently eulogized their editor Ben Bradlee with “His one unbending principle was the quest for the truth and the necessity of that pursuit.”
I can’t add anything at this time to the search for truth in dealing with Ebola and what sort of quarantine policies should be in place. The credibility problem is in the hands of politicos. The balancing of communal safety and individual rights is in the hands of judges. But whatever choices are made, medical ethics requires that they be implemented with respect and with compassion, which includes WiFi access. That is in the hands of nurses and doctors. So I will close with a quote from a meditation written nearly 400 years ago by John Donne, an English poet and cleric, during his own 3-week battle with a near-fatal illness.
“No man is an island, entire of itself; ... any man’s death diminishes me, ... therefore never send to know for whom the bell tolls; it tolls for thee.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
