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 SBMblog 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.
This article was originally published in the Science-Based Medicine Blog