I remember that first time- a parent insisting on antibiotics despite my advice. The girl clearly had a virus- cough and runny nose for two days. I explained to the father that antibiotics don’t kill viruses, she’ll get better regardless. “I still want the antibiotic,” he answered. No doctor likes to disappoint, but I didn’t give in. Better to anger a parent than prescribe unnecessary medications; as I explained to him, medications have risks.
In the past two decades, medicine has been touting “Antibiotic Stewardship.” As more antibiotics are prescribed, bacteria develop resistance to them. ”Super-bacteria” that resist all antibiotics sometimes infect patients. Scientists worry that one day, bacteria will win the battle, they’ll all become resistant to all antibiotics. The age of these miracle medicines will have passed, and a new medical dark age begun.
Antibiotics also are not entirely benign. They can have side-effects. Kids can get allergic reactions, sometimes just itchy hives, sometimes more severe. Antibiotics can cause diarrhea and yeast infections. Kids come to the Emergency Department for antibiotic reactions, and I sigh when the antibiotics were prescribed “for a cold.” Unnecessary medications can lead to unnecessary ER visits.
Since the Antibiotic Stewardship campaign hasn’t really changed prescribing habits, there’s now a program called “Choosing Wisely.” This new push is for doctors not only to prescribe medications carefully, but also stop unnecessary testing that can be potentially harmful, like unnecessary CT scans. All the major medical academies, like the American Academy of Pediatrics, have Choosing Wisely goals for their specialties.
Why are campaigns like Choosing Wisely and Antibiotic Stewardship necessary? Usage of medical testing and medication has skyrocketed, without improvement in health. The most stark example is the opioid epidemic: more Americans are now dying of narcotic overdoses than from car accidents. Part of the problem is consumer demand. We think that more is better, and that more tests, more medications, lead to better results. Also, everyone knows a story of someone who suffered or died because the doctor didn’t order this test, or give that medication. Then when their kid’s sick, they want it all.
Many people aren’t aware that tests can be harmful. When I discuss the risks of CT scans, I sometimes talk about this experiment: In August 1945, the Army Air Force dropped atomic bombs on two Japanese cities, Hiroshima and Nagasaki. The physicists knew how much radiation the explosions would put out for each given distance from ground zero. After the war, scientists followed the radiation effects in the victims. From this data, we know from those that got a radiation dose equal to a CT scan, that dose increases your risk of cancer a small, but real, amount.
Besides radiation risk, CT scans can also cause other problems. Often we need to give medical dye to “light up” inflammation for the scan, and that dye can cause allergic reactions. Also, scans carry the risk of “too much information.” Sometimes the scan shows not only what we’re interested in, like the appendix, but also shows other weird things we can’t explain. Usually those weird things are normal, but sometimes we can’t be sure. Then doctors are faced with a dilemma: do we spend more time and tests to prove that thing is cool, or do we just assume so and move on?
When people want more tests, like we discussed above, they’re often unaware that tests usually don’t declare the diagnosis, but only provide more clues. What’s not well known to the public (and some doctors!), is that most diagnosis, as much as 85%, is made from the medical history alone. The medical history is the “story” of the illness that doctors elicit from the patient. Taking a thorough history if far more important than tests. A good history also helps point to the best tests to do, or can eliminate the need for tests.
When the family wants a test or medication that the doctor is wary to order, there should be a clear conversation. The doctor needs to explain why the risks outweigh the benefits, that the test or medication may harm the child more than help. If the parents still insist, then the doctor either cedes to the parent’s request, if the harm is minimal, or must stand firm for the good of the child. Sometimes we make parents angry, in order to Do No Harm.