We do many things in medicine to patients that are either not helpful or have the potential to harm. If you take the long view of medical history, this should not be surprising. After all less than a century ago, physicians were still giving toxic mercury compounds to people in the form of calomel. And a century before that, physicians were bleeding people because they thought that was a good thing to do for serious illness. The dawn of scientific medicine in the late 19th century began the process of putting medicine on a scientific basis, that is, of demanding proof that a particular therapy works — and why. But we still have many, many things we do in medicine that have never been studied rigorously and are done more because of tradition than anything else. I have been encouraged over the past decade or so to see more and more of the accepted practices, therapies that have never been shown to be helpful, are being questioned. Treatment of respiratory syncytial virus (RSV) infection is a good example of this. We now follow fairly specific guidelines regarding what to do, guidelines which are based on actual evidence rather than tradition. Traditions die hard, though, and I still see some of my colleagues clinging to the older approach that has been shown not to help. We need to keep the stuff that works and discard that which doesn’t.
An interesting recent article asked the fundamental question of how many children receive one of our regrettably common treatments that not only don’t help but might cause harm. The authors focused on 20 of these, such as cough and cold remedies, and analyzed how many children in a database of over 4 million children received one or more dubious therapies during the preceding year. The results showed such unhelpful or even dangerous therapies are still extremely common. Around 10% of all children received such therapies, costing 27 million dollars, a third of which was paid out of pocket by the children’s families.
So what are these therapies? I noted the over-the-counter cough and cold remedies above, which have been shown at best not to help and at worst to cause dangerous side effects. Other examples include testing for strep throat in children less than three years of age, blood tests for vitamin D deficiency in normal children, sinus X-rays in children with an uncomplicated sinus infection and head CT scans (or other neuroimaging) in a child with simple headaches. You can read the whole list in the reference cited above.
The consensus estimate is that around a third of all medical therapies done in America are at best unhelpful and at worst potentially harmful. We in pediatrics need to do our part to address this problem. A major issue is that our culture is conditioned to regard doing something as better than not doing something. We are primed to think the physician who listens to the parents (or the patient), ponders what to do, and then recommends doing nothing is somehow a poor physician because they “haven’t done anything.” We don’t value the explanation, the thinking or the diagnosis, as an important contribution to a child’s health. The irony here is that physicians are highly compensated for “doing things” and much less for offering advice. So there is a strong compulsion to do something. Also, listening to a parent and pondering takes more time than just prescribing a test or a therapy and physicians are rewarded for throughput, seeing one patient after another quickly. The market incentives are perversely stacked against practicing good medicine. I wish I could say that will change, but I don’t see any hopeful signs that it will.
Christopher Johnson is a pediatric intensive care physician and author of Keeping Your Kids Out of the Emergency Room: A Guide to Childhood Injuries and Illnesses, Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments. He blogs at his self-titled site, Christopher Johnson, MD.
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