Millstone Pediatric Clinic
Above All Do No Harm

I started first-year medical school in 1974.  The first week of class one of our lecturers illustrated an irony.  We thought of the physicians that we were to become as something like saviours.  He told us that eighty per cent of the patients that we would see would get well without us if we would just stay out of the way and not order a test or perform a surgery or prescribe a medicine that they did not need.  Another ten per cent would have an incurable condition.   Only ten per cent of our patients actually need us. Wry comments and jokes reinforced the more humble position the physician actually occupies.  'If you don't hurry up and come up with a treatement they will just get better without you.'  The surgeon says to the internist, 'Don't just think about the case, do something!'   Or the internist says to the surgeon, 'Don't just do things to the patient, think!'

     An understood calling and challenge in Pediatric Residency was that top priority and urgency was placed upon identification and proper treatment of life-threatening illnesses.  A surprising find early in that same residency was that there was another priority and urgency close behind.  We were strongly pressured to avoid unnecessary diagnostic tests and unnecessary treatments for children.  Tubes for ear drums and tonsillectomies were therapies that had become popular to the point of being fads.  There was strong opinion among the pediatric faculty that many children were subjected to these unnecessarily.  Just prior to our time another fad intervention had been practiced called dilatation of the urethra.  Attending physicians spoke with relief that such an onerous procedure had been abandoned.

  How many such interventions can you think of.  One of my concerns is the unwise use of the emergency department at the hospital for symptoms such as fever or vomiting or allergic reactions.  Many of the parents explain their reason for checking into the hospital emergency room or urgent care center as, 'I just wanted to be sure that it wasn't something serious.'  Their visit is often within hours of the first symptom.  First, the emergency department is the best place you could possibly get to if you have a life-threatening condition whereas it is one of the worst places if you have an ordinary condition.  An emergency room physician is not your child's personal physician and cannot provide continuity of care.  He or she almost has to distrust you in the sense that you are an unknown.  You are treated by protocol and that includes protections that are built in in case you are not compliant with follow-up or treatment plans.  Because of this more things must be taken care of during the visit that would be just as well or better managed as contingencies that depended upon the course of the condition over a little longer passage of time.  Children will have more tests run, more doses of medicine given (especially Zofran and Rocephin and steroids), and more intravenous fluids infused.  Each and every test done and intervention administered carries with it its own risk to your child.

   Dr. Cassidy used to chide us as residents in his high-risk nursery that we were therapeutic opportunists.  He claimed the high ground of natural course of illness as the correct default posture.  In baseball the tie goes to the runner and in Dr Cassidy's nursery you had to prove to him that your intervention was justified by clear advantage over natural course of disease.  Otherwise he considered that the risk incurred by your intervention was unjustified.  Today however we live in what has been called a therapeutic society in which all are somewhat sick.  Technologic optimism has created a sense of security so that the public desires intervention rather than waiting and watching.  The old adage 'If it ain't broke, don't fix it,' holds in medicine as well as in life. Symptoms such as fever are universal and people generally fear fever.  Medical studies teach that immune advantages come with fever and that fever itself is not harmful to the child.  True, fever means that the child's immune system has an issue to deal with and we know that that issue is almost always a type of infection.  The infection is the matter that may or may not be serious.

   Children have what is called childhood illnesses and this denotes viral and bacterial infections that are part of the experience of the immune system in developing mature immunity.  Thankfully these are usually self-limiting and pose no threat to well-being.
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