I agree with you about shortening the course of disease.

I disagree that we should lower ourselves so we are practicing at the lowest common denominator. We need to educate our parents (and administrators) about the risks and benefits of medications. Otherwise, we should just put a large vat of amoxicillin in our waiting rooms and let parents decide when they want antibiotics.

James Chamberlain, MD
Division Chief, Emergency Medicine
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
202.476.3253 (O)
202.476.3573 (F)
202.476.5433 (Emergency Access)

-----Original Message-----
From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Dave Smith
Sent: Tuesday, June 01, 2010 4:29 PM
To: [log in to unmask]
Subject: Strep--Other Considerations

I want to play devil's advocate for a moment on another set of perspectives:

1.  What is the impact of not treating in terms of outcomes not considered by studies?

What I mean by this is that it is all well and good to pound the table and hold up the studies and say, "Best practice says I don't need to test/treat your 2 year old son, Mrs. Smith," but then, how often does Mrs. Smith go to the urgent care down the road where they invariably see a febrile toddler, order blood, urine and a chest xray, and give Rocephin?  Even if she goes to her PMD the next day and they simply do a strep and treat (which I think most PMD's would do despite our urgings to the contrary), she's now incurred another visit to another medical provider, increasing overall costs in the process.  In the former case, the child undergoes a while slew of tests and a treatment we could have prevented.  As I like to say, Evidence-Based Medicine is the beginning of wisdom, not the entirity of it.  We also have to practice "realistic medicine" ."  Over-adherence to dogma may lead to parents seeking other outlets that end up doing far worse
 than a script for PenVK.  Writing that script in some (many?) cases would thus be better practice than what the child ended up with even though it may not have been "best practice."

2.  We live in a world of Press-Gainey

If your hospital administrators are like ours, they don't really care about the best-practice guidelines...just the satisfaction scores.  When surveys come back giving the doctor a series of 1's because they doctor "didn't do anything about my child's strep throat and I had to go to an urgent care" they want to know what we are doing to improve our scores.  Telling them that strep only gets better a day earlier with treatment and the child wasn't in an age range for rheumatic fever so it didn't matter isn't something they care about.  That's how one ends up with language added to one's contract tying incentives and penalties to Press-Gainey performance.

3.  What's a day worth to a parent/child?

When your child is sick, would you like him to be better a day earlier?  As a parent of four, I would have to say my answer is yes.  Most parents I see would say yes as well.  That extra day could be two extra days in some cases and we have no way of knowing for could also be zero, but few parents would see that as an issue if there is a good chance the illness could be one or two days shorter.  For parents who are working, sometimes in positions where taking more sick days could mean not advancing or at the very least, being seen as unreliable because they are always out with "kid issues," that extra day might mean a lot.  So when we say, "It's not worthwhile because they only get better a day earlier at best," we are making a value judgement about the worth of a day of wellness and the value of the parents' time.

As I said, just playing devil's advocate.  I tend to agree in principle with what others have written in this thread.  But we must always remember that there are times when we still may be doing better care, given the balance of all the issues at hand, when we give a little ground on "best care."

Dave Smith, MD


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