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Outcome Bias in Clinical Decision Making and the Assessment of Our Peers

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There are many mental pitfalls and logical stumbling blocks faced by healthcare professionals when attempting to untangle the complex web of patient history and physical exam findings. They can impede our ability to practice high quality medicine at every step in the process, interfering with our ability to establish an accurate diagnosis and to provide comfort or cure. And we are all susceptible, even the most intelligent and experienced among us. In fact, having more intelligence and experience may even enlarge our bias blind spots.

Steven Novella discussed the complexities of clinical decision making in early 2013, specifically tackling some of the more common ways that physicians can come to a faulty conclusion in the third installment of the series. One cognitive bias yet to be specifically addressed on the pages of Science-Based Medicine, and it is one that I encounter regularly in practice, is outcome bias. Simply put, outcome bias in medicine occurs when the assessment of the quality of a clinical decision, such as the ordering of a particular test or treatment, is affected by knowledge of the outcome of that decision. We are prone to assigning more positive significance to a decision when the outcome is positive, and we often react more harshly when the outcome is negative. This bias is particularly obvious when the result of a decision largely comes down to chance.

I see outcome bias rear its ugly head in two contexts for the most part: the Lucky Catch and the Bad Call.

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Posted in: Science and Medicine

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Energy Drinks are Risky, Especially for Kids

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This is not for kids?

Last month I wrote a post on the causes of poor sleep in adolescents, as well as the myriad problems that can result in this high-risk population. Fortunately there is a system-wide public health measure proven to work, and now groups like the American Academy of Pediatrics are fully endorsing it. In that post, I briefly mentioned the increasing popularity of energy drinks and shots as caffeine delivery devices, and their role as both a potential cause of sleep deprivation and a means of temporarily ameliorating the effects.

I have been planning on addressing in greater detail the intentional, and unfortunately often accidental, ingestion of energy drinks in the pediatric population and the various associated risks for quite a while. What finally motivated me to get to work on this topic was the recent spate of media coverage regarding the results of a study presented this week at the American Heart Association’s Scientific Sessions 2014. The research, which involved the analysis of data obtained from the National Poison Data System for October 2010 through September 2013, supports concerns that pediatricians and other pediatric healthcare professionals have had for a very long time. Energy drinks are dangerous, particularly in young children, and a large part of the blame falls on the shoulders of manufacturers as well as the 1994 Dietary Supplement Health and Education Act (DSHEA) so frequently discussed on SBM.

Before I break down the scary numbers from the study, first a little background on energy drinks. (more…)

Posted in: Science and Medicine

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More Fear-Based Practice Building: Shaken Baby Syndrome and Chiropractic

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Unsafe playtime activity?

During my first clinical rotation in medical school, I found myself at the pediatric nurse station one afternoon waiting for a patient to arrive from the emergency department. An adorable older infant was there sitting in a bouncy chair, smiling and drooling as babies tend to do, and looking rather well for an inpatient. The nurse watching her explained that she had come a long way since first being transported to the facility by ambulance after being admittedly shaken (and almost certainly also beaten) by her mother’s new boyfriend one evening when she wouldn’t stop crying.

Now, cortically blind and facing a lifetime of disability, the child was awaiting placement by social services. I had experienced my first exposure to child abuse, a scourge of pediatric medicine that I hadn’t thought of at that point despite having decided on a career in pediatrics well before being accepted into medical school. I’ve since had many more opportunities to care for abused children, some of which involved considerably more visually disturbing findings and a couple that resulted in a child’s death. But I will never forget her and the feeling of utter revulsion I felt that day.

Child abuse is common and it comes in many forms that can involve physical abuse as well as neglect. Children under the age of 4 years are the most frequently affected, but children under a year tend to suffer the most severe manifestations. Head injuries make up the bulk of physical abuse in this age group, and they are often fatal. Roughly 40% of child abuse-related deaths occur in the first year of life and there is frequently both a history of abuse prior to the fatal event as well as missed opportunities for medical professionals to have intervened.

The head injuries that children suffer at the hands of abusive caregivers, if not fatal, are frequently still devastating. It is not uncommon for these children to suffer permanent neurologic injury which can include persistently altered mental status, cognitive impairment, cerebral palsy, blindness and recurring seizures. In addition to the child’s injuries, the psychosocial impact on the family can also be quite severe. I’ve seen families torn apart because of guilt and anger. (more…)

Posted in: Chiropractic

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The “It’s All Good!” Fallacy of Complementary and Alternative Medicine…..

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“Trust me, have I got a deal for you!”

As a young mother comforts her feverish and uncomfortable infant, a doctor enters the dimly-lit exam room. The child’s mother and the bedside nurse look at him expectantly.

“I’ve got the results. There is an infection in your son’s spinal fluid, which was one of the things we discussed as a possible cause of his high fever and irritability,” the physician explains to the now-crying mother. “We need to start treatment right away and admit him to the hospital.”

After answering the distraught mother’s questions and discussing her child’s treatment plan, the doctor leaves the room and begins to write orders in the patient’s chart. The nurse, eager to begin appropriate therapy looks over his shoulder with a confused look on his face.

“Excuse me doc, but you’ve got to be a little more clear on that order don’t you think?”

Written in barely-legible doctor scribble, next to the date and time of the encounter and above his signature and hospital number, is the lone word “antibiotics”.

“What do you mean? This child is sick and he needs antibiotics stat!”

“Sure doc, but which one, how much and how often? Where did you go to medical school again?”

“Clearly you aren’t current on the literature. Antibiotics have been around for decades and have been proven time and time again to treat infections. Millions of people take them every day and are pleased with the results. Now you are wasting precious time that could be spent caring for this sick child!”

The nurse, unhappy with the response, storms off to find assistance from his supervisor. The doctor, confident that he is providing competent medical are for his patient, expresses dismay at how closed-minded some of his colleagues are.

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Posted in: Science and Medicine

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Delaying School Start Times for Sleep Deprived Teens

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In August of this year, a new policy statement from the American Academy of Pediatrics was published which tackled the widespread problem of insufficient sleep in our adolescent population. They even went so far as to label insufficient sleep as “one of the most common, important, and potentially remediable health risks in children.” The statement, which gave a number of recommendations on how to address the problem, made the news rounds primarily because of the call for schools to delay start times until at least 8:30 AM.

I wrote about pediatric sleep in March for a post on the potential link between some sleep disorders in children, specifically nightmares and night terrors, and the development of psychosis. Those claims are suspect but please read that post for a review of what sleep is, why we need it, and what can go wrong with it in children of all ages. For this post, my focus will be on adolescent sleep specifically, and on the role of delaying school start times in improving a variety of health parameters.

What are the common adolescent sleep challenges?

The typical modern teenager faces a variety of challenges to consistently obtaining a full night’s sleep, which is considered by most sleep experts to be in the 8.5 to 9.5 hours per night range. This doesn’t mean that every teenager will fall apart if they only get 7 hours of sleep each night, but sub-optimal sleep can adversely affect school performance in many, and even lead to long-term health problems in some children who establish such a pattern during these pivotal years. Hold that thought for now, however.

One obvious reason for insufficient sleep in teenagers, at least it is likely obvious if you have one of your own or have ever spent more than two minutes near one, is technology. Most older children have electronic media in their rooms, if not attached to their bodies in the form of a smart phone. 24-7 access to the internet and social media is a commonly-cited impediment to sleep onset. The increasing availability and popularity of energy drinks containing absurd amounts of caffeine among adolescents likely also plays a role as both a coping strategy for daytime fatigue resulting from insufficient sleep, and as a cause of it. In fact, I think I’ve just come up with the topic for my next post.
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Posted in: Science and Medicine

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Hiccups: From Acupuncture to Quantum Touch

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Foolproof cure for hiccups?

nOne of the most common questions I get in the newborn nursery, especially from first time parents, involves hiccups. Babies hiccup in the womb and most, if not all of them, will have periodic bouts of hiccups in the neonatal period. But many new parents are surprised by their baby’s first spasmodic contractions of the diaphragm. When brought up, it is often to simply acknowledge that their baby had a run of a few hiccups, usually associated with a feed, with some parents expressing surprise and others nervousness. Regardless of their assumed motivation, I always provide reassurance that hiccups are a normal experience for babies, as they are across the entire spectrum of age.

The medical term for hiccups, which I admit I only learned while researching this topic, is “singultus.” We doctors like to use our own peculiar language as much as possible in order to maintain a sense of superiority when dealing with today’s internet savvy customers, I mean patients, and their families. The rumbling of your stomach, that’s actually borborygmus. You don’t have a unibrow above your nose, that’s a synophrys. It isn’t abdominal or pelvic discomfort associated with ovulation that keeps annoying you midway through your menstrual cycle, it’s mittelschmerz. But since this is a forum meant for general public consumption, I’ll use the rather pedestrian and philistine “hiccup” for the duration of the post. (more…)

Posted in: Science and Medicine

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A Touch to Fear: Chiropractic and the Newborn Baby

A significant part of my job as a pediatric hospitalist involves caring for newborns. It is arguably the best thing that I get to do as a physician, even if I do at times prefer the increased intellectual stimulation of the ill hospitalized child. While seeing newborns, I am almost always surrounded by happy and appreciative parents, grandparents and whoever else is invited to meet and greet the new arrival because the babies are almost always healthy. In fact, and not that I really care (sniff, sniff), the parents of newborns are with rare exception the only caregivers that ever thank me at discharge.

Unfortunately, sometimes I am called upon to assist babies that are having difficulty transitioning into the outside world for a variety of reasons. These reasons can range from the fairly minor and transient to the catastrophic. And despite our advances in the understanding of neonatal pathophysiology and in medical technology, there remain newborn infants that cannot be saved or who have severe lifelong deficits caused by their illness or injury. This will likely always be the case, especially if unqualified professionals continue to involve themselves in either the delivery or the care of babies.

Over the course of 11 years of practice, and after having seen thousands of both perfectly healthy and severely ill newborns, I have acquired a skill set which allows for the recognition of a baby in trouble and the ability to respond appropriately. All pediatricians and family doctors strive to develop this, particularly if they see patients in the newborn nursery, although I imagine none, including myself, would claim to have perfected this “art”. Newborn medicine can be very challenging for many reasons, not the least of which is the significant overlap of the presenting signs and symptoms of many serious conditions, with even normal baby behavior sometimes mimicking potentially life-threatening pathology. (more…)

Posted in: Science and Medicine

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Separating Fact from Fiction in Pediatric Medicine: Nocturnal Enuresis

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There is no role of chiropractic in treating childhood bedwetting

In pediatrics, very few things are completely black and white. This is an aspect of conventional medicine in general that tends to separate the approach of science-based practitioners from that of proponents of the many forms of irregular medicine commonly discussed on SBM. They appear to experience no shame in claiming absolute certainty while doling out all manner of implausible remedies for ailments ranging from the well-established to the fictional.

While we do face questions from patients and their caregivers regarding largely invented diagnoses in pediatrics, with chronic Lyme disease and non-celiac gluten sensitivity being just two of many increasingly encountered concerns, my experience has been that alternative medical providers tend to focus their efforts on the same real problems that pediatricians and family practitioners deal with on a daily basis. And I don’t believe that it is mere coincidence that these conditions are largely self-limited in nature, a fact often not shared. Parental and patient buy-in is often more easily obtained with certainty rather than nuance.

Chiropractors, for example, seem to pride themselves on their ability to cure ear infections. Of course in greater than 80% of children with acute ear infections, symptoms will resolve without any intervention whatsoever. This is why the AAP has been trying for years to decrease the rates of antibiotic prescriptions for ear infections, unfortunately with little in the way of success thus far. And when the infections don’t resolve on their own, there is no good evidence that anything a chiropractor has to offer can help. The same can be said for their claims regarding colic and gastroesophageal reflux, which I’ve written about before.

Another condition frequently mentioned by chiropractors as being particularly in their wheelhouse is nighttime bedwetting, the medical term for this being nocturnal enuresis. Rarely have I seen a chiropractic website with a section on the benefits for children that does not mention their success in curing bedwetting. Fred Clary, DC, even claims on his website to be able to cure bedwetting in the newborn baby. And to think I’ve just been ignoring the problem as a newborn hospitalist. Is it because the thought of a newborn infant gaining continence is absurd, or am I just a shill for Big Pampers?
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Should the Incidental Discovery of Nonparentage be Disclosed?

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“Ummm, I probably shouldn’t be telling you this.”

The July issue of Pediatrics, the official journal of the American Academy of Pediatrics, contains an extremely thought provoking article discussing the risks and benefits of disclosing an incidental finding of nonparentage during pediatric genetic testing. Nonparentage occurs when one, or very rarely both, of the social parents did not serve as source code for a child’s genetic programming, so to speak. Naturally, we aren’t talking about known adoptions but rather when the nonbiological parent is unaware of the fact that they did not contribute an egg or sperm.

Authors Marissa Palmor and Autumn Fiester, both bioethicists at the University of Pennsylvania’s Perelman School of Medicine, take the position of universal nondisclosure when nonparentage is discovered. They acknowledge the pro-disclosure arguments and, in my opinion, successfully rebut them. They go on to make a compelling recommendation for the incorporation of a universal nondisclosure clause into consent forms which states clearly that parental status will not be discussed. (more…)

Posted in: Medical Ethics

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The Buzzy: Revolutionary Acute Pain Management or Simple Distraction…

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I’ve written about the management of acute pain in children in the past, and unfortunately my feelings haven’t changed in the interim. Acute pain, particularly pain related to procedures such as venipuncture for blood sampling and intravenous access, and intramuscular administration of medications such as antibiotics and vaccines, is commonly undertreated, downplayed and even ignored altogether by medical professionals and even caregivers. So when I was made aware of a device being used in pediatric clinics and emergency departments (and even available for home use) with apparent success in preventing or reducing procedural pain in children, I was intrigued and more than a bit hopeful. (more…)

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