The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
The practice of medicine is an art, based on science.
-Sir William Osler, AEQUANIMITAS
The truth is that many of us have some kind of “extraordinary gift.” For a few of us, that gift is the ability to throw a ball at 90 miles per hour and hit a catcher’s glove. For others, that gift is a form of extraordinary perception. Medical intuitives “see” things that others don’t. Wendy Marks has been described as a “human CT scan.” What no one has been able to diagnose by conventional methods is often seen when Wendy scans a body.
-Boston Women’s Journal April/May 2002
The concept of an art to the practice of medicine comes up frequently and in a variety of contexts. Early on in our medical education, we are exposed to the phrase and what it supposedly means, which I will discuss in more detail shortly. But the art of medicine is always painted (pun intended) in a positive light. I will admit that I have a strong opinion, perhaps biased by my involvement with the science-based medicine movement and an equally early exposure during my medical training to champions of evidence-based practice and the use of critical thinking in the approach to patient care.
By now, regular SBM readers should be aware of the Choosing Wisely initiative. Just in case, Choosing Wisely is a campaign developed by the ABIM Foundation to bring together experts from a variety of medical specialties in order to identify common practices that should be questioned by patients and providers, if not outright discontinued. Their ultimate goal was not to establish treatment guidelines or dictate care, but to foster discussion. As I’ve written about in a prior post on the overuse of antibiotics in pediatrics, it doesn’t appear to have caught on. I routinely ask colleagues, residents and students if they are aware of it, and am frequently disappointed by their response.
The American Academy of Pediatrics issued a list of five questionable practices back in February of 2013 and I loved it. All five are important:
- Stop treating viruses with antibiotics
- Stop prescribing and recommending cough and cold medicines for young children
- Stop routine use of CT scans for minor head injuries
- Stop routine use of neuroimaging for simple febrile seizures
- Stop routine use of CT scans for abdominal pain
By far the most common medical problem in newborn infants is jaundice, typically appreciated as a yellowish discoloration of the skin caused by increased blood levels of a pigment called bilirubin. In my role as a newborn hospitalist, I manage jaundice every day. If I am not treating jaundice, in every single baby I see I am at least determining the risk of the child developing jaundice severe enough to require treatment. I then use that assessment to help guide my recommendations on when the infant should follow up with their primary care pediatrician after discharge home.
Fortunately for the millions of infants who develop jaundice every year, in the vast majority it is a self-limited process and often considered to be just a normal part of the first few days of life. But in a significant minority of them, careful management is required in order to prevent complications. Some infants need treatment to prevent neurological symptoms from developing, and to reverse them when they do occur. And in a very small percentage of babies who develop severe jaundice, permanent brain damage and even death can occur.
Because newborn jaundice tends to resolve without any intervention, and complications are now uncommon, it isn’t surprising that a variety of myths and superstitions have arisen that involve preventing or curing the condition. And naturally there are practitioners of unproven alternative medical modalities that can be found claiming to be able to manage it as well. As expected, if you’ve spent any time reading Science-Based Medicine or researching the nonsensical claims of chiropractors, homeopaths and their ilk, their understanding is limited and their recommendations potentially dangerous.
But first a crash course on newborn jaundice. (more…)
As I write this post, a large outbreak of mumps is ongoing in Columbus, Ohio. The city, which on average sees a single case each year, has seen over 250 since February. To put things in further perspective, only about 440 cases are normally diagnosed in the entire United States annually. The outbreak began on the campus of Ohio State University, where about 150 cases have been identified, but no information about the index case has been reported thus far.
Although the current outbreak will likely smolder for months, the total number of cases thus far is considerably fewer than the worst of the past decade. A 2009-2010 outbreak in New York and New Jersey ended up affecting about 3,000 people. In 2006, about 6,500 college students throughout the Midwest were infected. It is unlikely we will see these kinds of numbers in Ohio, but even our worst in recent years pale in comparison to those that have occurred in England over the past decade, where there was a peak of about 56,000 documented cases in 2005.
The diagnosis of only a few hundred cases per year is a clear victory of the mumps vaccination program, which started in 1967. Prior to the widespread adoption of the vaccine, 186,000 cases were seen in the United States annually. That works out to a decrease in cases of over 99%. This reduction didn’t occur because of improved sanitation, cleaner water, or even sunspots. It occurred because of the hard work and dedication of vaccine researchers, medical professionals and the widespread public acceptance of a safe and effective vaccine.
Mumps doesn’t get the kind of press that measles outbreaks do. There are a number of reasons why this is true and reasonable. I will get into more detail, but essentially mumps, although it can result in significant morbidity, just isn’t as sexy and it isn’t a good candidate for anti-anti-vaccine poster child. Measles wins in that regard, and let’s hope it stays that way. I am terrified at the thought of HiB meningitis returning. But that doesn’t mean that mumps outbreaks can’t serve as fodder for educating the public on vaccines. First though, a primer on mumps.
Science Based Medicine last covered the increasingly common practice of laboring while immersed in water, in many cases followed by delivering the baby while still submerged, a little over four years ago. In that post, Dr. Amy Tuteur focused primarily on the contamination of the water with a variety of potentially pathogenic bacteria and the associated risk of infection. She also touched on the some of the other risks of giving birth underwater and made some excellent arguments against many of the claims made by proponents. I recommend reading that post and the ensuing comments.
This week, a new joint clinical report from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) on immersion in water during labor and delivery was published in both the April Pediatrics and on the ACOG website. The media has responded with the typical flurry of falsely dichotomous coverage, pitting maternal-fetal medicine experts against midwives and other waterbirth proponents and leaving it up to the reader to decide which side is right. This March 23rd, an NPR article by Nancy Shute is a particularly frustrating example of weak medical reporting. In the article she essentially portrays giving birth underwater as an established and safe practice and medical experts as overly focused on a few flimsy anecdotes and case reports:
“Case reports are the lowest form of evidence,” Shaw-Battista counters. She is completing a study of 1,200 women who labored or birthed in water, and says they did as well or better than women who did not. “Given the bulk of the data, I don’t think we should use case reports to reject options that women are currently enjoying.”
Earlier this month, the typical media outlets were abuzz (“Childhood nightmares may point to looming health issues“) with the results of a newly published study linking early childhood nightmares and night terrors with future psychotic experiences. Expressing little in the way of skepticism, most reports simply regurgitated the University of Warwick press release. The research, published in the quite legitimate journal Sleep, is interesting but I’m not sure it tell us anything that we don’t already know. And it certainly doesn’t support any causal relationship between sleep disorders of any variety and “delusions, hallucinations, and thought interference”. But before we delve into the specifics of the paper, I believe a quick review of sleep, and sleep problems, in children is in order.
What is sleep?
To the outside observer, sleep appears as an altered level of consciousness where response to our environment and voluntary movements are noticeably decreased. But, with a certain degree of variability, the line between sleep and wakefulness is pretty thin. This distinguishes it from the increasing stimulation required to reverse other states of altered consciousness such as lethargy, obtundation, stupor and ultimately coma, which is not acutely reversible. I don’t plan on getting too technical, but there is obviously much more to sleep than that. Physiologically our metabolic demands drop a bit, and we enter a generalized anabolic or “growth” state during which a number of beneficial processes take place, predominantly, we think, involving the brain.
Sleep is a vital aspect of human life that has appears to have both physiological and psychological purpose, and is essentially universal in the animal kingdom. All you need to do is observe a cat for more than five minutes to see that we aren’t the only animal species that both needs and seemingly enjoys sleep. In fact, if you could talk to a nematode, it would likely go on for hours about how much it enjoys sleeping in on Sundays. Humans spend roughly a third of their lives asleep, but the percentage of each day devoted to sleep is significantly higher during infancy and early childhood.
We don’t know why the need to sleep became part of the blueprint for life so early on in our evolutionary history, and researchers certainly haven’t worked out all of the nuances of why humans and other animal species continue to be so dependent on it throughout the lifespan. It is likely that its purpose has broadened over time as species branched out into new environments. There are a number of leading hypotheses, however. And barring some amazing technological or medical advance, we appear to be stuck with sleep.
Pollyanna, a popular children’s book written in 1913 by Eleanor H. Porter, introduced the world to one of the most optimistic fictional characters ever created. She always saw the good in people and her approach to life frequently involved playing “The Glad Game”, where she attempted to find something to appreciate in every situation no matter how unfortunate. She was glad about receiving crutches rather than a doll one Christmas because it was great that she didn’t actually need them. She teaches this philosophy to those around her, even her cantankerous Aunt Polly, and the entire town is transformed into a veritable Mayberry, USA. Later, when she actually does require the use of crutches, her resolve is tested but she triumphantly finds a silver lining.
The Pollyanna principle, first described by Matlin and Stang in 1978 and also known as positivity bias, is a psychological tendency for people to place greater importance on, and assume better accuracy of, descriptive statements about them that are positive. This goes on behind the scenes while our conscious brain tends to dwell on what is perceived as negative stimuli. Though many folks do come across as pessimistic, we are subconsciously biased to accept praise and reject criticism. Anyone who isn’t clinically depressed is on some level more like Pollyanna than Eeyore.
This positivity bias also plays a large role in how we remember past events. As has been covered extensively in prior posts here on SBM, and on Dr. Novella’s excellent Neurologica blog, memory isn’t a replayed video or audio recording of prior events and our interpretations of them, but rather is a reconstruction that is prone to errors during processing and editing that accumulate over time. This leads to false memories that feel no less real than our recollection of what happened five minutes ago.
In this case, the Pollyanna principle results in positive information being more accurately processed and recalled than negative experiences. It also causes our memory of negative events to gradually become less negative as the years go by. I couldn’t have done that terribly during my first high school trumpet solo because I remember people telling me it was pretty good afterwards, right?
So what does this have to do with the practice of medicine? Biases that affect memory also impact how physicians and patients interact. I once assumed the overnight care of a child who had undergone a lumbar puncture performed by one of my female colleagues earlier that day. I ordered no tests and performed no procedures during my brief exposure to the family—yet over a year later when I admitted the same child for a completely different reason I was accused of being the terrible doctor who had unnecessarily subjected their baby to a spinal tap during the last hospitalization. Even after I showed them the documentation which proved that I had nothing to do with that (very appropriate) decision, and that I did not put a needle in their child’s spine, they refused to accept the evidence and had great difficulty trusting my diagnosis and recommendations.
The following post is a collaborative effort between myself and science-based dentist Grant Ritchey DDS. Dr. Ritchey is a co-host of the always excellent The Prism Podcast, most recently interviewing Dr. Robert Weyant and discussing how to teach critical thinking to dental and medical students. He can also be found on Twitter at @SkepticalDDS. Dr. Ritchey has written for SBM before on the topic of cranial osteopathy in dentistry.
As a pediatric hospitalist, I don’t deal with issues of dental health very frequently. Sure I see plenty of oral mucosal lesions, as occur during a primary herpes outbreak or a case of Kawasaki disease, but not many problems with the teeth themselves. I do admit a few dental abscesses here and there that need to be cooled down with IV antibiotics prior to definitive surgical drainage. And as a hospitalist that sees a fair amount of newborns, I also discover the occasional natal tooth. That’s when a baby is born with a tooth, usually a central mandibular incisor, having already erupted.
But as a pediatrician, I care deeply about the overall health of children and the network of caregivers that surround them. I guess you could say that I take a holistic approach, but I would prefer that you didn’t. Although we aren’t dentists, pediatricians recognize that oral health is integral to the well-being of a child and that many long-term dental maladies develop during the first two decades of life, often before the first tooth even appears. The most common, and one which non-dentist health care providers can have a major impact on, is the development of dental caries, or “cavities”. (more…)
One of the most commonly practiced strategies used by parents to alter long term behavior of their children is corporal punishment, commonly referred to as spanking. But use of the term spanking is problematic in that how caregivers interpret it varies widely, and there is frequent overlap with what pediatricians consider to be abuse. Despite a great deal of evidence showing that spanking is ineffective, is a risk factor for greater forms of physical abuse and can negatively impact the behavioral and cognitive development of children in a variety of ways, it remains a controversial issue in the United States. The American Academy of Pediatrics and numerous other professional organizations have come down firmly against the use of physical punishment by parents, but unlike 34 other developed nations there are no federal laws banning spanking.
Laws regarding corporal punishment vary from state to state. 19 states currently allow the striking of a child in any school setting. Of the 31 states and the District of Columbia that ban the practice in public schools, only New Jersey and Iowa also include private schools. Many schools give the misbehaving child a choice between suspension and being beaten with a paddle. It is also common for schools to require a parent to opt out of their child receiving corporal punishment rather than having to sign a consent form before such physical correction is applied. Corporal punishment in schools is more prevalent in the South and in lower socioeconomic school districts, leading to poor black children being by far the most likely to face it.
Currently no state has a law that explicitly bans corporal punishment in the home. In fact, most state laws have specific language in their statutes on abuse, assault, battery, or domestic violence that make exceptions for spanking by a caregiver. In 2012, new child abuse legislation in Delaware made the news because it might possibly be interpreted as making spanking illegal. The law was put into place to serve as a means of improving the ability to protect children from physical abuse, but the language was vague. The lawmakers claim that it is not meant to interfere with parents who choose to use “reasonable force”, whatever that means, and do not cause injury. (more…)
In August, news emerged from Vanderbilt University that four cases of a rare bleeding condition seen in young infants had been diagnosed since February. Three of these infants suffered intracranial hemorrhages, requiring surgical intervention to evacuate the blood and save their lives, although there will almost certainly be neurological and developmental repercussions down the road. The fourth child presented with gastrointestinal bleeding and also survived. The parents of all four babies had refused an extremely safe and effective intervention on the day that they were born, one recommended by pediatricians since the early 1960′s, that would have prevented these outcomes.
When a baby is born, there are a number of rituals that parents and medical professionals take part in. Some are largely ceremonial, more rites of passage than anything medically necessary, such as the first bath or the assignment of APGAR scores. As a physician, I play my part in some of these rituals, the baby’s first exam being the most important. Unlike many medical examinations that pediatricians perform, the newborn exam involves a good deal of showmanship. It’s the only exam where I make a point of talking through each aspect with the parents, showing them all the normal but sometimes surprising (at least to new parents) things that babies do and common physical exam findings that many folks don’t know about and might lead to unnecessary concern. Really hammering home how healthy a new baby is can go a long way towards relieving parental anxiety. And anticipating and addressing common newborn issues during the exam helps save me a lot of time on the back end as well.