Articles

Suffer the Children

Some of our readers have complained that we pick on alternative medicine while ignoring the problems in conventional medicine. That criticism is unjustified: we oppose non-science-based medicine wherever we find it. We find it regularly in alternative medicine; we find it less frequently in conventional medicine, but when we do, we speak out.   A new book by Dr. Peter Palmieri is aimed squarely at failure to use science-based medicine in conventional practice.

Dr. Palmieri is a pediatrician who strives to provide the best compassionate, cost-effective, science-based care to all his patients. Over 15 years of practice in various settings, he observed that many of his colleagues were practicing substandard medicine.  He tried to understand what led to that situation and how it might be remedied. The result is a gem of a book: Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care. Its lessons are important and are not limited to pediatrics: every health care provider and every patient could benefit from reading this book.

The chapters cover these subjects:

  • How doctors mishandle the most common childhood illnesses
  • How doctors succumb to parental demands
  • How they embrace superstition and magical beliefs
  • How they fall prey to cognitive errors
  • How they order the wrong test at the wrong time on the wrong patient
  • How financial conflicts of interest defile the medical profession
  • How doctors undermine parents’ confidence by labeling their children as ill
  • A prescription for change

There have been huge advances in pediatric care in recent decades. As Palmieri aptly puts it,

Devastating infectious diseases such as polio, smallpox and diphtheria were so utterly vanquished that many otherwise reasonable people, apparently afflicted with an odd and dangerous form of selective amnesia, now openly embrace misguided anti-vaccination efforts.

Premature infants as small as 8.6 oz have survived; survival rates for childhood leukemia have soared; surgery is being performed on fetuses in the womb; organ transplants have become routine.

Unfortunately, these remarkable achievements in the high echelons have not translated into improvements at lower levels of pediatric care. The most common illnesses are handled poorly in many doctors’ offices. Antibiotics are given for viral illnesses where they can’t possibly work (Palmieri compares this to putting a mousetrap in the kitchen to combat an infestation of ants). Doctors often rationalize that antibiotics are needed to treat “occult bacteremia” or “sinusitis” when the patient really only has a routine cold. As a result, antibiotic resistance is rising and we have to worry about MRSA (Methicillin-resistant Staph aureus). Some physicians have forgotten or abandoned their scientific training and have adopted erroneous beliefs from dubious sources. They commit errors not through lack of knowledge or of intelligence, but as a result of human fallibilities in the context of complex interactions between patient, doctor, and society. Palmieri provides insights into how those errors arise, with trenchant stories of patients who suffered from those errors.

He debunks a number of common myths, such as the idea that fever is dangerous (the only real reason for treating it is comfort) and the belief that white coats frighten children (this was studied and shown to be false).  For treatment of vomiting and diarrhea, Palmieri points out that the traditional “bowel rest,” 24 hours on a clear liquid diet, and the BRAT diet (bananas, rice, applesauce and toast) are not based on evidence and are no longer recommended by the CDC or the American Academy of Pediatrics; yet the myth refuses to die.

This book cuts to the heart of why science-based medicine is important and why it is so difficult to implement. The subject of each chapter of Palmieri’s book deserves an SBM blog post of its own. I’ll just give one example here that highlights several of the issues at once.

A 14 year old boy with viral gastroenteritis had vomited several times over a few hours. The pediatrician decided he was dehydrated or about to become dehydrated and admitted him to the hospital for IV fluids and an overnight stay. Palmieri, who was responsible for his care in the hospital, estimated that he was only mildly dehydrated. He treated him with anti-emetic medication and oral rehydration. After a very short time, the boy was keeping fluids down, ate a light lunch, and felt much better. He improved enough to be discharged later the same day. Meanwhile, Palmieri was harassed by the parents, the referring pediatrician, and the hospital administrator. The father demanded to know why his son didn’t have an IV and why blood tests hadn’t been done; Palmieri provided him with a printout of CDC guidelines on dehydration and explained that he was following them precisely and would not need to start an IV unless oral rehydration failed. The father was still hostile, insisting that the pediatrician had clearly said his son would be spending the night in the hospital. The referring physician called Palmieri wanting to know why the child didn’t have an IV yet, insisting that he needed one because he was dehydrated. The administrator complained that the hospital wouldn’t be paid by the insurance company unless they inserted an IV to prove that he was sick enough to be in the hospital, and he wanted to know why Palmieri was being a troublemaker and refusing to do what all the other doctors did. Palmieri followed the standard of care, did what was best for the child, and minimized the cost and discomfort of treatment, but no one was happy (except the child). In the face of that kind of opposition, many doctors are tempted to take the easy way out, give in to the expectations of others, waste more money, do unnecessary tests and procedures, please the parents, and generate more profits.

When Mom insists that Tommy always gets an antibiotic for his runny nose and it is the only thing that cures his supposed “sinusitis,” it’s far easier to write another prescription than to go against all his previous doctors and try to explain why antibiotics aren’t indicated. And anyway, Mom won’t listen: her mind is firmly made up. She is going by what other trusted doctors have told her, by her personal experience, and by her strong desire to do what she believes is right for her child. If you don’t write the prescription, she will only find another doctor who will.

Current reimbursement systems reward poor medical care. A doctor may get $65 for an office visit to appropriately treat a child with an ear infection. If he codes it as “fever” he can be reimbursed for a barrage of unnecessary tests (flu, rapid Strep test, CBC, tympanometry, reimbursed at $15 per test) and charge for a higher complexity visit ($85), raising the total charge for an office visit to $145. And then if the white blood count is elevated, he can justify giving an antibiotic by intramuscular injection at an additional charge of $30-$50. One doctor told Palmieri he does circumcisions in his office because Medicaid pays for them, but he sends simple lacerations to the ER because Medicaid won’t pay for office suturing. Financial considerations are particularly tempting to pediatricians, since their incomes are typically the lowest of any specialty.

Palmieri argues that poor care inflates medical expenditures, while good care is cost-effective. The money that is being wasted on unnecessary measures would be sufficient to provide quality care to all the children who currently lack access to care.

This is not your typical doctor-bashing book. He does not criticize conventional medicine per se: he applauds those who practice it successfully in accordance with scientific evidence and only criticizes those who fail. And he is charitable to those who fail: he shows how easy, how human, how understandable it is to fall into error. He recognizes that his own bias in favor of scientific rigor might lead him into errors of his own, and he tries to keep that constantly in mind and guard against it.  He’s not just a critic: he has concrete recommendations for improvement. Parents should become better educated to recognize which symptoms are normal variants or self-limiting illnesses and should accept that not every complaint requires treatment. Doctors should

  • Listen more carefully
  • Observe more vigilantly
  • Be more humble
  • Constantly question what they know
  • Be more diligent
  • Improve their communication
  • Work hard to maintain competency and engage in life-long learning
  • Not succumb to financial temptations
  • Care more deeply for their patients

Suffer the Children is available as an e-book at very low cost. It has some typos and grammatical infelicities that would have benefited from professional editing and proof-reading, but it is written with an engaging style and should appeal to everyone from the most science-illiterate layman to the most sophisticated medical subspecialist.  There is too much in this book to do it justice in a short review: it even provides a short course in cognitive errors and why doctors believe weird things. In future posts I’ll try to address some of the other important issues it brings up. Please read this book, and recommend it to all your friends (and enemies, for that matter), especially those with children.

Posted in: Book & movie reviews, General

Leave a Comment (27) ↓

27 thoughts on “Suffer the Children

  1. windriven says:

    Among Dr. Palmieri’s recommendations to his peers is to “[n]ot succumb to financial temptations.”

    A reasonable corollary is that we (through insurers and government) have an obligation to build incentives that encourage the desired result.

    Anyone who has ever managed people knows the adage: ‘be careful what you incentivize for because you’re likely to get it.” The point being that incentives often have unintended consequences and one must be careful when constructing them.

    Poorly constructed reimbursement incentives is one of the causes of the high cost of medical care in the US – and one of the profound failures of health care reform efforts.

  2. windriven says:

    For those of you with a Kindle, Amazon’s price for the digital edition is $3.99.

  3. Mhops says:

    Thank you for discussing this book!

    Almost every day in clinic I become aggravated with the way antibiotics are given in such a lazy, careless fashion. I typically fail to see any evidence that standard diagnosis guidelines for such common diseases as acute otitis media, acute bacterial sinusitis, acute tonsillitis, acute otitis externa are ever followed.

    As an Otolaryngologist, I am referred patients who have “failed” multiple courses of antibiotics for consideration of surgical treatments. In large part, I have to rely upon the referring provider to have made the proper diagnoses in the past to justify a procedure (if I want to follow standard guidelines). What — that 3rd course of antibiotics did not resolve your sinus infection? Has anyone considered that perhaps it isn’t a sinus infection at all? Did anyone consider that perhaps this, like most sinus infections, is viral? Perhaps the Otolaryngologist you just saw doesn’t even care and just wants to operate?

    We are making decisions to perform surgery on adults and children that I fear are sometimes supported by a house of cards.

  4. delaneypa says:

    Thank for the review, Dr. Hall. It again reminds us of the overuse of antibiotics. Parents of sick children want them better. Antibiotics is an easy placebo-by-proxy for them. It is an combination of art and salesmanship to address parents’ concerns using nonpharmacological approaches. The parents who are willing to learn that antibiotics are not antipyretics are, in the long run, less demanding and happier.

    In any case it seems that while MDs over prescribe antibiotics, others sources may be playing a bigger role:

    http://news.consumerreports.org/health/2011/04/study-drug-resistant-staph-found-in-us-meat.html

  5. moderation says:

    Thanks for the review … I will be downloading it today.

    I have been in practice for 15 years and see continued improvement in the approach pediatricians, family practice physicians, urgent care physicians and ER doctors take to common childhood illnesses … though there continue to be significant differences in the rates at which these recommendations are applied among the various specialties. Residency training programs are doing a better job of teaching the latest AAP (science based) recommendations. It takes a while for changes to percolate through to established physicians. Some do a great job of keeping up to date on the latest research and recommendations, but as with anything habitual behavior is difficult to break.

  6. Anthro says:

    Thanks for letting us know about this book. My kids are grown and I guess I lived in simpler times. My children only saw a pediatrician once or twice, mostly we all saw the same “family practice” doctor and usually a phone call reporting the temperature was all that was needed. We did use the rule of 24 hours with no food for vomiting–or “stomach flu” as we called it. I didn’t know this was debunked. Why would you offer food/liquid to someone who can’t keep anything down? I always thought the BRAT diet was silly for the same reason.

    None of my four children were ever seriously ill or hospitalized, but I can say that we had very no-nonsense doctors who were very clear about the over-use of antibiotics and were always happy to explain this to us, as well as reassure us that our kids would be fine with ordinary let-it-run-its-course treatment (supplemented with the lots of fluids, rest and TLC, of course).

    I remember when one of the boys got “cooties” after a camping trip. I had no experience with head lice and got a bit hysterical. Finally the doctor put up his hand in a “stop” gesture and said, “it’s only bugs for god’s sake!–use the shampoo and calm down”. I was miffed at the time, but certainly appreciate his rationality in the long run.

  7. The Blind Watchmaker says:

    I am a Pediatrician and an Internist. I downloaded this book and look forward to reading it. From the sounds of it, I will likely be sharing it with my patients as well.

    I also recommend “Taking the Medicine” by Druin Burch for a general overview of how non-scientific thinking held back medical science (and still is).

  8. Harriet Hall says:

    @The Blind Watchmaker, “I also recommend “Taking the Medicine”

    I recommended it first!
    http://www.sciencebasedmedicine.org/?p=5038

  9. BenAlbert says:

    I like the idea of this book. However as a Paediatric trainee in New Zealand, in a highly evidenced based medical culture, the examples you gave seem mostly irrelevant to our system. For context Paediatricians essentially all work in secondary or tertiary public hospitals in New Zealand.

    Overprescription of antibiotics is a major problem by General Practitioners in the community in NZ, perhaps they should read this. The payment model is different in New Zealand taking away significant financial advantage for ordering unnecessary tests or giving unnessary treatments. Treating a child in the hospital, in normal circumstances I would never have an administrator come and try to convince me to order a test or give a treatment. I understand, the US has Paediatricians in the community who fill this role, and under a private payment model. If community Paediatricians in the US are often unable to diagnose a simple viral URTI then there must be something enormously wrong with Paediatric training.

    Antibiotic prescribing for URTIs by paediatricians is rare except in the case of concomitant otitis media – a contentious area. Oral rehydration therapy is standard treatment, with IV or NG fluid being used as a last resort in the dehydrated patient who fails ORT or cannot keep up with losses. I have to admit I have never heard of the BRAT diet, but applesauce is not popular here, so that sounds very regional. Working against families opinions about best treatment is always hard, but advocating for the best treatment for the child is the responsibility of a paediatrician, and this means having difficult discussions when they are necessary – I am sure some Paediatricians capitulate more easily than others here.

    Overall perhaps my view of my colleagues is too rosy, but the applicability of this book seems to me, (from your review) to be limited to countries with a system of paediatric care like the US. Of course this may have been the authors intentions, and I’m making more of a comment than a criticism. Some of it might be more applicable to NZ general practitioners who are the providers of primary care paediatrics.

    -Ben

  10. I realize that most people who are on this site are doctors, but you should know that 80% of U.S. antibiotic use is for food animals. Over-prescribing them to your human patients is a drop in the bucket compared to preventative use in food animals.

    http://www.foodpolitics.com/2011/04/the-politics-of-contaminated-meat/

  11. Harriet Hall says:

    @BenAlbert,

    Perhaps I did the book a dis-service by citing the antibiotic example. Some practices vary with culture and setting, but the book covered a number of issues about how doctors think and the cognitive errors we are all subject to. It has lessons for every one of us.

  12. BenAlbert says:

    Maybe I will give it a look, as I said the idea of such a book, skeptically looking at Paediatric practice interests me a great deal.

    -Ben

  13. BillyJoe says:

    The situation in Australia is similar to that decribed for New Zealand.

    There are Paediatricians in private practice here, but they are never the first port of call. All patients see a General Practitioner first and, only if the problem is too complex for the GP to handle, is the patient referred to a Paediatrician. As a result, community Paediatricians would rarely, if ever, be ordering antibiotics except as long term prophylaxis for conditions such as recurrent UTIs. Similarly there is no incentive for either GPs or Paediatricians to order blood tests or investigative procedures.

  14. I’ve downloaded the book. I’m curious to get the full story on the Regarding the anecdote of the boy in the hospital.

    I guess I was under the impression that when someone was admitted into the hospital, that the orders of the admitting doctor would take precedent. I can understand why the parents would be upset. Their regular doctor, who they trust, says the son needs an IV, the doctor in the hospital, who they’ve never met, who’s never examined their son before, and who probably doesn’t have a complete record of the son’s medical history, takes a different course, without getting buy-in from the admitting doctor or the parents. It just sounds a bit high handed to me.

    But, of course, maybe there are details in the book that put his actions into a different light.

    I think it’s good to note that the ability to coordinate efforts with coworkers and communicate effectively with patients or the parent of patients also have an impact on the cost of Healthcare.

  15. grr, iPad comment, sorry for the editing errors, but I think one can get the idea of what I’m attempting to say.

  16. moderation says:

    Interesting differences from the US to Australia and New Zealand. In the US pediatricians are considered primary care physicians … for children. Family Practice physians also see children (comparable to what you are calling a “General Practitioner”). I know the numbers vary greatly as to the percentage of pediatric patients Family Practice doctors see each day. The FP’s I have worked along with or have known see anywhere from a few pediatric patients a day to a few a week. I am sure there are some FP’s who see more than that, especially in areas where a pediatrician may not be available, however I have worked mostly in larger cities.

  17. JPZ says:

    Excellent review. Thanks!

  18. A.A. says:

    I think this will be the fourth book I purchase as a result of reading Dr. Harriet Hall’s review. (The Emperor of All Maladies, a book I bought after reading Dr. Harriet Hall’s glowing review on SBM, recently won the Pulitzer prize. Much Deserved.)

  19. services billing boston MA says:

    Another view to the suffer the children way:-
    Contemporary Authors New Revision Series, vol. 40: “Saul’s first novel, about a dysfunctional family in a small New England town.
    Get full details the series to find the updates.

    http://www.deltamedicalbilling.com/

  20. Newcoaster says:

    While I don’t have a lot of pediatric patients in my family practice, I still see many during my ER shifts. Really sick kids are always scary and challenging, but overbearing parents with a Dr Google education are the biggest problem I ever face with unwell kid (aka wheezer and sneezers)

    I could relate to the case of the “dehydrated” child as I have run across that scenario many times. The parent has been told by the walk-in-clinic doc that their child needs IV fluids/antibiotics/pediatrician referral…….and then I tell them, “well, actually….”
    I understand why some docs give in to parental pressure. It is usually easier to run some tests, order an IV, prescribe some antibiotics than to take the time to explain why none of that is needed. I think part of our job is education though, and I do take the time to explain. Most of the time, parents are appreciative once they understand. Occasionally there is the angry door slam and the “I’ll take him to a good doctor”, but you can’t please everybody.

    The billing system in Canada is different…I get a flat fee based on the visit and whether its a regional or a complete exam…so there is no way to “pad my billing” based on the diagnosis code, or what tests I order.

  21. The Blind Watchmaker says:

    I have read most of the book so far. As a pediatrician, I gotta tell ya’ that he is on the money. I personally encountered anecdotes comparable to many (if not most) of the situations described.

    As a resident in the ER, I have had private attendings chew me out on the phone for not using IV hydration on mildly dehydrated kids who were doing fine on oral rehydration.

    I have had many moms threaten to report me to someone or another for not giving antibiotics for colds (fortunately less and less as my practice matures).

    I have had insurance companies reject hospital stays because patients responded to conservative measures and did not meet criteria.

    In residency, attendings showed me how to do stains on kids nose swabs to show bacteria under the microscope. This justified the antibiotics and a charge for a procedure. The fact that everyone’s noses have bacteria did not seem to matter (I think they knew this but wanted to rationalize the antibiotic use).

    Critical thinking in medicine is critical for all doctors and for their patients. This is an important book. Hopefully, a publisher will pick it up and promote it.

  22. The Blind Watchmaker says:

    @Newcoaster

    “overbearing parents with a Dr Google education are the biggest problem I ever face with unwell kid (aka wheezer and sneezers)”

    Love it.

  23. Harriet Hall says:

    A pediatrician I used to work with said the practice of pediatrics consisted mostly of benign neglect of children and emotional support of parents. He sometimes wished he could perform a parentectomy.

Comments are closed.