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Summary of Pitfalls in Clinical Practice
Summary of Pitfalls in Clinical Practice
Many of the pitfalls presented in this and the preceding number of the Pediatric Clinics can be categorized as follows: Overtreatment. Only rarely was undertreatment ( undermedication) mentioned. Too many surgical procedures are being performed, particularly tonsillectomy and adenoidectomy, repair of umbilical hernia, casting of physiologic orthopedic deformities, and so on. Poor Choice of Medication. When a choice of medication is possible, the more toxic, more expensive or less effective form is frequently used. It was possible to ascertain that errors of overtreatment frequently were usually due to the "need" to placate the mother (or father, neighbors, and others). Sometimes there appears to be undue curiosity on the part of the physician who wishes to explore a new diagnostic or therapeutic method, not yet clinically proved. The errors in the choice of medication appear to be due to ignorance, bias or sheer force of habit. An essential ingredient of good clinical judgment is that the risk of therapy (drug, exchange transfusion, surgical procedure, and so forth) does not outweigh the probable clinical benefits. Although controlled clinical studies have not been reported which allow one to settle many important clinical controversies, there frequently are sufficient data to justify the safest course. For example, in the opinion of many, tonsillectomies and adenoidectomies are still performed too frequently, since the risk of death (approximately 1:5000) or serious morbidity (1:500) outweighs the possible advantages (of, say, one or two fewer respiratory infections a year for a few years, after which time spontaneous tonsillar atrophy occurs). Antimicrobial therapy, nose drops and cough medicine are given far too frequently for colds and minor respiratory infections, since the expense and possible drug complications outweigh the minimal clinical benefits. On the other hand, possibly sedatives and aspirin are not given enough.
377
378
SUMMARY OF PITFALLS IN CLINICAL PRACTICE
Many indicated, "off the record," that physicians are often intimidated into doing something (e.g. giving nose drops, cough medicine or penicillin injections, or taking out tonsils) for even simple colds in order to keep patients satisfied. Others mentioned that it takes too much time to explain that certain symptoms or diseases (e.g. cold, bronchitis) will run a natural course and that therapy is worthless. Therefore they give something. It would appear, therefore, that an inexpensive, completely safe placebo should be used in such instances or, better, that a warm, nonprofessional aide should be employed who could take the time to educate and reassure apprehensive parents. Possibly physicians should prepare a series of pamphlets explaining the nature of those common disorders which are uninfluenced by medications. Such pamphlets are available for a few, relatively uncommon serious disorders. Although overtreatment has been stressed, there was evidence of errors of omission, presumably due to lack of specific information. We must all be on guard to pre.vent becoming outdated; we require periodic "retreading." Others expressed their feelings as follows: "The worst pitfall in clinical practice is to limit oneself to being a baby doctor rather than a pediatrician and family counselor." "The worst errors are overactivity, overtreatment, overdiagnosis." This is an example of the "vissicitudes of the tinkering trades" (Irving Gofman). "Not maintaining standards, or succumbing to community standards: this is one of the greatest pitfalls." "From a philosophical standpoint, the physician should avoid the pitfall of settling down to an exhausting routine of a very large practice and then using what little time is left for himself and his family in a frantic pursuit of having a good time." "Somehow the physician should take time-preferably a quiet fun time-to be with his family, and allow time for church, study, teaching and active participation in medical societies and, hopefully, some participation in civic affairs. If he can do all these things and stay healthy and alive, he should be happy (and stay in pediatrics) ." It was repeatedly mentioned that many physicians who assume responsibility for the health care of children freely disregard emotional problems. Much can be said in defense of the general physician who shuns emotional problems and fails to obtain a social
SUMMARY OF PITFALLS IN CLINICAL PRACTICE
379
history. This can be illustrated by presenting the problem in reverse, as follows. A child psychiatrist mentioned how simple it is to obtain a psychiatric-social history, and that it takes but a little effort and training to take care of many cases of anxiety, depression, and the like. When, however, this psychiatrist was asked whether he had reviewed the medical record of a patient with Addison's disease who had recently been referred to him, he said, "No, it was too specialized a problem." It was then pointed out that the diagnosis and treatment of Addison's disease are relatively simple, usually much less taxing than the diagnosis and treatment of anxiety or depression. On reflection, the psychiatrist agreed with this judgment. He then seemed less inclined to be critical of the nonpsychiatrically oriented physician (he himself considered himself nonorganically inclined) who chose to assume direct responsibility for emotional problems. Physicians have strong individualistic interests, abilities qnd backgrounds, and they often have limited competence in certain specific areas, e.g. surgical, psychiatric-emotional, administrative, cardiac. Among physicians who care for children, however, there should be a serious attempt by those who do not have interest or skill in emotional-psychiatric disorders either to hire an aide to help them or to refer patients to competent community or private agencies where disorders in emotion and behavior can be handled. There is no doubt, however, that the child's physician must learn how to recognize such problems; he must learn to identify the symptoms, signs and situations which are related to emotional imbalances. This is a minimal obligation for the clinician who assumes responsibility for the health of children. Pitfall number 257 (p. 107, February number of Pediatric Clinics) evoked considerable discussion; from some criticism, but from others, praise. It should be noted that many who oppose iron supplementation of formulas for infant feeding do not oppose the unrestricted use of "solids," particularly iron-enriched cereals. Their position appears to be a paradox, because most iron-enriched baby cereals contain 1 mg. of iron per 4 to 8 calories-or 10 to 20 times the iron content of iron-supplemented formulas. Yet those who oppose iron supplemention are not concerned that infants eat indefinite amounts of iron-enriched cereals. Some infants receive much more iron from cereal alone than they could ever receive from an iron-supplemented formula.
380
SUMMARY OF PITFALLS IN CLINICAL PRACTICE
Similar inconsistency in logic can be noted when the problem of iron consumption in adolescents and adults is considered: those who oppose iron supplementation of milks (because the small amount contained might be harmful) do not restrict the intake of foods (meats, and so on) which have a relatively high iron content; in fact, they frequently urge that large quantities be consumed. It should be noted that the consumption of milk or formula is much more stable in the first year of life than of any other food, and that they are virtually the sole source of calcium: why not also, therefore, of iron?
Many of the pitfalls presented in this and the preceding number of the Pediatric Clinics can be categorized as follows: Overtreatment. Only rarely was undertreatment ( undermedication) mentioned. Too many surgical procedures are being performed, particularly tonsillectomy and adenoidectomy, repair of umbilical hernia, casting of physiologic orthopedic deformities, and so on. Poor Choice of Medication. When a choice of medication is possible, the more toxic, more expensive or less effective form is frequently used. It was possible to ascertain that errors of overtreatment frequently were usually due to the "need" to placate the mother (or father, neighbors, and others). Sometimes there appears to be undue curiosity on the part of the physician who wishes to explore a new diagnostic or therapeutic method, not yet clinically proved. The errors in the choice of medication appear to be due to ignorance, bias or sheer force of habit. An essential ingredient of good clinical judgment is that the risk of therapy (drug, exchange transfusion, surgical procedure, and so forth) does not outweigh the probable clinical benefits. Although controlled clinical studies have not been reported which allow one to settle many important clinical controversies, there frequently are sufficient data to justify the safest course. For example, in the opinion of many, tonsillectomies and adenoidectomies are still performed too frequently, since the risk of death (approximately 1:5000) or serious morbidity (1:500) outweighs the possible advantages (of, say, one or two fewer respiratory infections a year for a few years, after which time spontaneous tonsillar atrophy occurs). Antimicrobial therapy, nose drops and cough medicine are given far too frequently for colds and minor respiratory infections, since the expense and possible drug complications outweigh the minimal clinical benefits. On the other hand, possibly sedatives and aspirin are not given enough.
377
378
SUMMARY OF PITFALLS IN CLINICAL PRACTICE
Many indicated, "off the record," that physicians are often intimidated into doing something (e.g. giving nose drops, cough medicine or penicillin injections, or taking out tonsils) for even simple colds in order to keep patients satisfied. Others mentioned that it takes too much time to explain that certain symptoms or diseases (e.g. cold, bronchitis) will run a natural course and that therapy is worthless. Therefore they give something. It would appear, therefore, that an inexpensive, completely safe placebo should be used in such instances or, better, that a warm, nonprofessional aide should be employed who could take the time to educate and reassure apprehensive parents. Possibly physicians should prepare a series of pamphlets explaining the nature of those common disorders which are uninfluenced by medications. Such pamphlets are available for a few, relatively uncommon serious disorders. Although overtreatment has been stressed, there was evidence of errors of omission, presumably due to lack of specific information. We must all be on guard to pre.vent becoming outdated; we require periodic "retreading." Others expressed their feelings as follows: "The worst pitfall in clinical practice is to limit oneself to being a baby doctor rather than a pediatrician and family counselor." "The worst errors are overactivity, overtreatment, overdiagnosis." This is an example of the "vissicitudes of the tinkering trades" (Irving Gofman). "Not maintaining standards, or succumbing to community standards: this is one of the greatest pitfalls." "From a philosophical standpoint, the physician should avoid the pitfall of settling down to an exhausting routine of a very large practice and then using what little time is left for himself and his family in a frantic pursuit of having a good time." "Somehow the physician should take time-preferably a quiet fun time-to be with his family, and allow time for church, study, teaching and active participation in medical societies and, hopefully, some participation in civic affairs. If he can do all these things and stay healthy and alive, he should be happy (and stay in pediatrics) ." It was repeatedly mentioned that many physicians who assume responsibility for the health care of children freely disregard emotional problems. Much can be said in defense of the general physician who shuns emotional problems and fails to obtain a social
SUMMARY OF PITFALLS IN CLINICAL PRACTICE
379
history. This can be illustrated by presenting the problem in reverse, as follows. A child psychiatrist mentioned how simple it is to obtain a psychiatric-social history, and that it takes but a little effort and training to take care of many cases of anxiety, depression, and the like. When, however, this psychiatrist was asked whether he had reviewed the medical record of a patient with Addison's disease who had recently been referred to him, he said, "No, it was too specialized a problem." It was then pointed out that the diagnosis and treatment of Addison's disease are relatively simple, usually much less taxing than the diagnosis and treatment of anxiety or depression. On reflection, the psychiatrist agreed with this judgment. He then seemed less inclined to be critical of the nonpsychiatrically oriented physician (he himself considered himself nonorganically inclined) who chose to assume direct responsibility for emotional problems. Physicians have strong individualistic interests, abilities qnd backgrounds, and they often have limited competence in certain specific areas, e.g. surgical, psychiatric-emotional, administrative, cardiac. Among physicians who care for children, however, there should be a serious attempt by those who do not have interest or skill in emotional-psychiatric disorders either to hire an aide to help them or to refer patients to competent community or private agencies where disorders in emotion and behavior can be handled. There is no doubt, however, that the child's physician must learn how to recognize such problems; he must learn to identify the symptoms, signs and situations which are related to emotional imbalances. This is a minimal obligation for the clinician who assumes responsibility for the health of children. Pitfall number 257 (p. 107, February number of Pediatric Clinics) evoked considerable discussion; from some criticism, but from others, praise. It should be noted that many who oppose iron supplementation of formulas for infant feeding do not oppose the unrestricted use of "solids," particularly iron-enriched cereals. Their position appears to be a paradox, because most iron-enriched baby cereals contain 1 mg. of iron per 4 to 8 calories-or 10 to 20 times the iron content of iron-supplemented formulas. Yet those who oppose iron supplemention are not concerned that infants eat indefinite amounts of iron-enriched cereals. Some infants receive much more iron from cereal alone than they could ever receive from an iron-supplemented formula.
380
SUMMARY OF PITFALLS IN CLINICAL PRACTICE
Similar inconsistency in logic can be noted when the problem of iron consumption in adolescents and adults is considered: those who oppose iron supplementation of milks (because the small amount contained might be harmful) do not restrict the intake of foods (meats, and so on) which have a relatively high iron content; in fact, they frequently urge that large quantities be consumed. It should be noted that the consumption of milk or formula is much more stable in the first year of life than of any other food, and that they are virtually the sole source of calcium: why not also, therefore, of iron?