CONFESSIONS OF A PÆDIATRICIAN

Saturday 26 October 1963 CONFESSIONS OF A PÆDIATRICIAN * JOHN APLEY M.D.

Lond., F.R.C.P.

CONSULTANT PÆDIATRICIAN, UNITED BRISTOL HOSPITALS AND BATH CLINICAL AREA; SHAW LECTURER IN DISEASES OF CHILDREN, UNIVERSITY OF BRISTOL

THE traditional Seven Deadly Sins have no exact counterparts in medicine, and I group these confessions, not very logically, under errors of word, deed, and thought. The examples given are only illustrations, like those on seed packets, of the profusion that lies within easy reach. Errors of Words

" Words are tools for thinking," wrote Huxley, and " He who does not know the force of words cannot know men," said Confucius. Words are the vital link between doctor and doctor, and between doctor and patient; yet we study them so little. What we do not say and what we do say, how we say it and when we say it, may make the difference between helping and not helping our patients. I confess that like most doctors, even television doctors, I used to err by telling the parents of a child with congenital heart-disease, a septal defect, that he had " a hole in the heart "; I have learnt that a phrase like " a small gap in the muscle " leaves them better prepared to play their part, but I am still dissatisfied and think I should do better. I invite you to become members of The Anti Phoney Phrase Club. To join you have only to cull a loose or " phoney " phrase, of which there is no shortage in our as common examples professional jargon. I mention " " There’s nothing wrong ", Don’t worry " and " He’ll grow out of it ". These phrases are too often used with such common childhood disorders as recurrent headache or abdominal pain, yet with a moment’s thought their inadequacy is exposed. There is something wrong, even if it is not an organic disorder, or the child would not have been brought for advice. If the parents do not worry, what sort of parents would they be ? The child often does not grow out of it or the symptoms are replaced in adult life by others, as was clearly shown in a Bristol survey. The error of using such phrases may lead to incorrect treatment; it may leave patients and parents dissatisfied with themselves, their own doctor, and all doctors; and it may leave the doctor dissatisfied with himself and with his work. Some doctors are miserly and others spendthrift with words; but with patients nearly all of us tend to be precipitate. We talk too soon. I may do this, and you may do this, to save time. But with many of the complicated disorders of modern civilisation talking too soon does not save our time in the long run; and with many more it wastes the time of the patient, the parents, and the com* Based on an address to the Shrewsbury Medical Society, April 19, 1963.

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munity. A related error, which I freely confess, is not listening carefully or enough. Sir Thomas Lewis, that great clinician, expected his housemen to be as accurate as he in eliciting physical signs-but not in obtaining the history. With a stethoscope or without, Lewis knew what listen for. That facile expression " The patient did not cooperate indicates an error of communication that is traceable not only to words but to the attitude behind them. Of the partners in the cooperative exercise between doctor and patient, only the former is usually aware-or should be aware-of the need to understand and avoid the difficulties. I am trying to train myself to correct this sort of error by writing (legibly) in the notes, not " The child (or the mother) did not cooperate ’, but " I failed to obtain cooperation "; just as I have cultivated the habit of saying at the beginning of every outpatient clinic to students who are present " If any child brought here cries it will be my fault ". But I admit that what started as open confession, as an investment in truth for its own sake, has been paying unexpected dividends: my failure-rate, which I hope was never high, is certainly lower since the students and I have learned to watch for my errors.

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Errors of Deeds Diagnosis Many errors of diagnosis are due to doing too little, often through being hurried; many errors of treatment to doing too much, again and paradoxically through being hurried. Diagnostic errors due to a failure of observation seem to become less frequent with increasing seniority,

but I sometimes suspect that this may be an illusion created by the tact of one’s juniors. For fear of falling too often into the error of observational complacency I prescribe for myself an occasional refresher course of reading old masters: you may recall Henoch, in the 1880s, writing meticulously on what we now call neonatal cold injury; and Charles Darwin, who studied but quickly abandoned medicine, with his punctilious description of the baby’s crying, in a delightful though little-known book The Expression of the Emotions in Man and Animals. Errors in diagnosis inevitably occur, but we can learn from them. Why do I so carefully examine the teeth of every child with unexplained fever ? Because once, in a child with " n.u.o. ", when an unexamined tooth fell out and an abscess drained itself, both the temperature and my self-esteem fell dramatically. We learn painfully from avowed error, but learning can be no less painful when others make the mistakes. Why do I always insist on removing the napkin when I examine an infant, whatever the complaint ? Partly because I once had the thankless task of diagnosing pseudohermaphroditism in a 5-year-old girl, brought up as a boy, who at 3 months of age had been examined, but with the napkin in situ, by a clinician I had previously admired.

848 I confess that one of my errors of deed is on occasion to admit children to hospital when admission might have been avoided; when I could have done my job in the outpatient department if I had given enough time, or if my energies had not already been drained by seeing too many patients while trying to remain both human and humane. But once the child is in hospital I get him out very quickly, perhaps because the time I spent in general practice taught me a lesson: that. " hospital illness " is not an entity but only an episode in the life of the patient and his family. The episode should be made as brief and as harmless as possible; it may even be made beneficial, if it is used purposefully not to erode but to repair the confidence of parents in their ability to care for their children. In hospital probably the most frequent errors of deed are over-investigation and over-reliance on investigations. The danger is not alone that of harming the patient but also of undermining the faith of the doctor in himself. For these errors a severe but just punishment is that insidious and often unperceived disorder of doctors-disuse atrophy of the clinical senses and clinical judgment. The error of over-investigation was brought home to me when a colleague and I studied children with " growing pains ". We found incidentally that, while physical growth is not a cause of pain, emotional growth often is. Among 213 children, our detailed laboratory and X-ray investigations pointed to a causative physical disorder in only 7. In later studies of children with recurrent abdominal pain the same lesson was repeated: among " little " bellyachers perhaps 1 in 20 has an organic disorder, and in diagnosis over-investigation can be not only misleading but dangerous, for the doctor himself " may become a pathogenic agent in his well-meaning but never-ending efforts to find a physical cause ". Years ago my youthful, starry eyes were dazzled by experts reporting on esoteric investigations. But, to give two examples only, I have since seen several children who were " written off when air encephalograms showed " cerebral atrophy " but whose mental development proved to be unimpaired; and among 200 healthy schoolchildren I found that in a quarter the electroencephalo" grams were reported to show a significant " abnormality. A fundamental error underlying excessive investigation is often a morbid preoccupation with a symptom or a system, and neglect of the person as a whole. To correct the error we need " the whole doctor for the whole patient ". Avoiding the error of over-reliance on ancillary investigations may, of course, lead to errors of omission; but examples are surprisingly hard to come by. We do not want to become clinical Canutes, trying to hold back the tide of scientific progress; but the informed clinician, not the technician, must make the decisions about patients. Treatment Both inside and outside hospital a prevalent error is excess of treatment. I distrust textbooks of treatment, because they imply that everything should be treated. Rabelais, himself both doctor" and drinker, was less presumptuous when he wrote: A hundred devils leap on my body if there aren’t more old drunkards than old

physicians." We are constantly having to re-learn that there is no absolutely safe drug: not oxygen or penicillin, not even water (for over-hydration may be lethal). Even for the trusted salicylates a formidable list of disadvantages can be drawn up: they may cause bleeding in the gut, and shed-

ding of the tubular epithelium in the kidney; in heartfailure they may provoke pulmonary oedema, and in pregnancy they are suspected of teratogenicity. Quoting in justification the Chinese proverb " Do not take a hatchet to remove the fly from your friend’s forehead ", I confess that I have turned so much against drug treatment that now I tend to. prescribe too infrequently. As a result, when I do prescribe I may have to rely on my junior colleagues to tell me the dose. Many hurried practitioners quickly give a prescription as a means of saving time; and if all does not go well they may change the prescription, perhaps from one antibiotic to another. It may save more time if, when things do not go as expected, the diagnosis rather than the prescription is reconsidered. I was recently asked to see a child with a respiratory infection whose condition, after improving on tetracyline, suddenly became worse. The harassed family doctor wanted advice on a change of antibiotic and was a little put out when I suggested reconsidering the diagnosis. In the event a lobe of one lung had collapsed. Errors of

Thought

I know a brilliant child psychiatrist, one of whose virtues is sometimes carried so far as to become a fault: he may identify himself with his patient. Parents can more easily manage the child than the child-psychiatrist who sets out to shock them. This colleague’s error is one from which most of us are fortunately free: we are more likely to identify with the parents and give the child (or even the psychiatrist, who collects such objets d’art) a piece of our

mind. An

to which many of us are prone is an fear of being caught out in a wrong diagnosis: exaggerated I wonder if in this we are concerned not so much for the patient’s welfare as for our own prestige. When this fear leads to interminable follow-up examinations and to overinvestigation, it is harmful not only to the patient but also to the doctor. I recall a small girl who had repeated attacks of diarrhoea which remained unexplained after months of intensive investigations by determined, almost desperate, doctors who left no metaphorical stone unturned and no bodily avenue unexplored. After even a jejunal biopsy had been done, I was asked to see the parents. All that was needed was to encourage them to talk. It then became apparent that the diarrhoea occurred every time the father, a sailor, went cruising with his ship; but by then the damage to the family, and possibly to the doctors, had probably become irreparable. An error of thinking that I must confess is oversimplification. The dramatic diagnoses and cures which I recall, and cherish, from my youthful forays, but which become rarer with time, seem on looking back to have been welcome compensations for the loss of perspective which goes with over-simplification. Nature appears simple only to the simple; Nature is complex, and so is Man, in health as in disease. The medicine that ignores this is too often incomplete and may be grossly misleading. " Honest-toGod Conjoint-type diseases " exist in unsullied purity only in the examination hall. I confess that it is still tempting to isolate the person from the family and community of which he is an inseparable part; to label him a " patient "; to split him tidily into two (mind and body); and neatly to dissect the body into systems, tissues, and organs. To overcome this all too persistent naivete, based on an error which is as much philosophical as medical, I try to cultivate " the comprehensive approach ", though with varying success. error

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diagnosed congenital heart-disease (a small ventricular septal defect) in a girl 14 years old, but advised the parents to let her play and exercise as much as she wished. When they said that she was set on becoming a ballet-dancer, I became cautious, and pointed out that ballet was among the most strenuous of all pursuits. Partly because of the girl’s insistence, cardiac catheterisation was carried out and the diagnosis confirmed. The parents compelled her to give up ballet. I saw her again seven years later by chance at a medical meeting, where she was demonstrated as a young woman with an insignificant cardiac anomaly but with a crippling cardiac neurosis. To me, if to nobody else, the part I had played in its causation was painfully obvious. Cultivating the comprehensive approach is, I hope, helping me also to correct a further error of thinkinginertia. I use the term not to express inactivity but (in the sense in which it is used in physics) to express " a tendency to continue in the existing state (whether of rest or of uniform motion) ". It is too easy to go on in just the way we started; the sort of things we learned as students may be the only sort of things we will ever try to learn. Typical of my generation, I entered consultant practice knowing something about children’s diseases but almost nothing I

HYPERTENSIVE CRISIS DUE TO MONOAMINE-OXIDASE INHIBITORS

once

about children. All credit to the National Health Service which supports me, in comfort if not in affluence, while I try to overcome the inertia and correct my ignorance. Uses of Error

I do not wish to imply that the only benefit conferred by error is the opportunity of learning to do better. Either chance or error may lead to unexpected discoveries. You will recall Horace Walpole’s story " The Three Princes of " Serendip (an old name for Ceylon), in which the heroes " were always making discoveries of things they were not in quest of ". Cats provide an example of medical serendipities. When M. L. Barr and E. G. Bertram were looking for evidence of neurone fatigue in cats they observed, unexpectedly, a prominent mass of chromatin in some neurones. Going back over their specimens, they found the chromatin not in toms but only in female cats. As a consequence the whole field of what is crudely called " nuclear sexing " was opened up. In contrast A. Vogl, while a third-year medical student in Vienna, made a discovery not through chance but through error. His chief had ordered inorganic mercury for a girl with congenital syphilis but, unable to obtain it, Vogl prescribed an organic mercurial preparation. He redeemed this error by observing the diuresis that followed each injection, and thereby a new class of diuretics was discovered. I believe that if we think back many of us may recognise personal errors or serendipities, of importance to ourselves if not to others. Much of my own interest in the comprehensive approach stems from the time when, studying bodily symptoms with the determination to find physical causes to explain them, I was led to " the discovery of the whole

patient ".

Finally

I mention

one

skill that I

am

from practice in the avowal of errors:

hoping to acquire

confess as graceYet I shall never achieve the confessional virtuosity of a very senior and eminent surgeon, whose letter I cherish. In it he wrote: " It has made me feel young to have been given this new idea." There is much more that could be said; but I must end while I remember a remark overheard at the National Gallery: " We shall never get out of here if you keep

fully

as

stopping

I

am

to

able.

look

at

things."

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B. BLACKWELL B.A., M.B. Cantab. PSYCHIATRIC REGISTRAR, MAUDSLEY HOSPITAL, LONDON,

S.E.5

SINCE the euphoriant effect of iproniazid was first noted in the treatment of tuberculosis the monoamine-oxidase inhibitors have become widely used in the treatment of depression. Although monoamine oxidase participates in the metabolic degradation of serotonin and the catechol amines the precise pharmacological actions of its inhibitors remain uncertain, and their side-effects are sometimes unexpected. Hypertensive crises due to phenelzine have been reported by Dally (1962) and Taylor (1962), but are commoner with tranylcypromine. Earlier studies of this drug made no mention of the syndrome (Agin 1960, Lemere 1960), but Lurie and Salzer (1961) noted that 2 out of 84 patients had had " a devastating headache accompanied by a transient rise in blood-pressure ". In this country, Clark (1961) discontinued an early trial of the drug after encountering the condition in 3 out of 30 patients. Brown and Waldron (1962) reported 6 cases amongst 150 patients (4%) in their general practice, and Burke and Lees (1963) noted the side-effect in 11 out of 60 patients (18%). Because of the many unexplained features of the hypertensive crisis and its possible relevance to the mode of action of the drugs, further patients were sought, and 12 were collected in six months. All except 2 patients were interviewed within a few days of the incident, and 4 were seen during an attack. Clinical Features The salient clinical features are set out in the table. 10 of the 12 patients were women, and all were under 50 years of age. This frequency is probably a reflection of the patients for whom these drugs are most often

prescribed. patients were receiving tranylcypromine, and in 8 of these drug was combined with 1 m.g. of trifluoperazine as the proprietary preparationParstelin ’; 1 patient was taking amphetamines concurrently, but the remainder were taking no other drugs; 1 patient (case 10) was receiving phenelzine. There was no constant time relation between the taking of the tablets and the onset of symptoms, although most often the patient received the last dose at midday and experienced the syndrome in the evening. None of the patients was taking an excessive 11

the

dose but a noticeable feature was the wide variation in duration of medication from three days to sixteen months. 3 patients (cases 7, 8, and 11) were able to continue taking the drug without a recurrence of symptoms. These features of the crises diminish the likelihood of normal toxicity or idiosyncrasy and suggest the possibility of an exogenous precipitating factor. This supposition is supported by an examination of the dietary history. 2 patients were not seen soon enough after the incident to obtain a reliable account (cases 7 and 9), but 8 of the remaining 10 had eaten Cheddar cheese, either cooked or raw, within half to two hours of the attack. In some instances this was as little as 22 g. in amount. 2 inpatients had symptoms at the same time after the only cheese provided during the week. In half of the patients the longstanding dietary regimen was unusual. 4 patients were taking low-carbohydrate high-protein diets. 1 was a vegetarian, 2 were on diets for obesity, and the 4th was on a regimen prescribed for her husband’s functional hypoglycxmia. 2 other patients had a low dietary intake

sporadically supplemented by high-protein feeds (’ Complan ’). In

5 and 12 cheese was not eaten before the attack; 5 ate ’Marmite ’ two hours before the attack. This product is principally composed of the peptides and aminoacids cases

case