Patient Care

Release the Ritual


As bronchiolitis season approaches, my thoughts turn to the yearly struggle that is practicing medicine with others, to include residents, nurses, primary-care providers (PCPs), respiratory therapists, families, colleagues, and subspecialists. What seems to go reasonably well during other parts of the year or with other diagnoses seems to always fall apart at one point or another during “the season.” Inevitably, some manner of awkward conflict will arise with regard to what to do next. I already am filled with anticipation, much in the way that my mouth puckers at the thought of a tart lemon.

It shouldn’t be too much of a stretch for most practicing pediatric hospitalists to understand these feelings. While the care of children hospitalized for bronchiolitis can be remarkably straightforward—watch, wait, and repeat—we recognize that our entire winter existence is filled with machinations of what others seem to want to do to our vulnerable, wheezy infants. Some days I feel as if I am a lone villager defending my baby from possible iatrogenic injury of these marauding tribes.

Although the attackers might be imaginary, the harms are certainly real: irradiation, over-broncho-salinebulization, the antibiotic-probiotic cycle, rhinitis suctionitosa, exsanguination, and, of course, shaken infant “physiotherapy.” If I could grow a beard, I would take my hooded sweatshirt to Montana, because mid-season, that would be my coping mechanism of choice.

In clearer moments, I don’t really see any villains. I simply see human nature. Families come to us looking for a cure. Residents order labs and X-rays because they aren’t sure and they think fancy tests will help (who hasn’t ordered an ESR and CRP in analogous situations?). Nurses and respiratory therapists see improvement after patients visit the ICU pharmacy and wonder why we can’t try those magical drugs pre-decompensation.

As a general rule, the more uncertain and frightening the situation, the more we humans gravitate toward something (perceived to be) more powerful than ourselves for help.

We use the term mythology to describe how the ancient Greeks dealt with this. In medicine, interventions become our myths when we are faced with clinical uncertainty. Or, as I like to say, the less you know, the more you do. When we are dealing primarily with self-limited diseases, our interventional rituals result in overutilization and iatrogenesis.

Pediatric medicine is filled with classic examples of self-limited diseases. Bronchiolitis is the classic inpatient example. Gastroenteritis is another one. Viral pneumonia is a bit of chameleon, but it’s more common than most realize. And lest we forget our outpatient colleagues, we should keep in mind that every day the clinic is filled with visits for colds, viral pharyngitis, or harmless dermatoses.

Think of how much drug companies spend on marketing drugs for cough and cold medicines instead of investing funds into more research for effective antimicrobials.

The Myths of Healing

“Treatments” commonly are used in an attempt to ameliorate the acute course of all these diseases, but not without a healthy degree of safety and/or economic arguments against intervention. I was always taught that the best pediatricians treat only self-limited diseases because everything that they do works. I can pretty much guarantee that whether I give someone with a cold methotrexate or eye of newt, they eventually get better. With all of these diseases, less is more.

As a resident, I remember writing prescriptions for decongestants when my clinic attending told me to, or when I didn’t know how to handle the family. It took the FDA to make the world a safer place for children with colds. A child in Bangladesh with diarrhea and moderate dehydration given oral rehydration and early re-feeding is likely safer than the child receiving intravenous fluids and “clear liquids” in America. Did you know there are actually case reports of iatrogenic kwashiorkor after treatment for gastroenteritis in this country?

Moving beyond safety, the economic imperative for cost-effective care should not be a foreign concept by now. I shudder to think about how the child in Bangladesh might have gotten better for a few pennies, while the child in the U.S. was billed for an ED visit and overnight stay for “poor follow-up.” Waste also comes in forms other than direct costs: Think of how much drug companies spend on marketing drugs for cough and cold medicines instead of investing funds into more research for effective antimicrobials.

As physicians, we know we are doing too much. In a recent report in the Archives of Internal Medicine (2011;171:1582-1585), nearly half of the doctors surveyed felt that their patients received too much care, as opposed to only 6% that felt that they were receiving too little. Reasons for overtreatment included malpractice concerns, clinical performance measures, and inadequate time to spend with patients. The bottom line is that it is often easier to do more than to justify a safer, more cost-effective, and evidence-based course of less intense care. We know what we do.

Our Hospitals, Our Plight

Returning, then, to the wards in winter, how is a lone and oft-overworked hospitalist to solve these problems? Evidence helps, a little. Guidelines built into the flow of care help, a little. Agreement amongst your colleagues helps, a little. But ultimately, I see this as a communication issue.

And by communication, I do not mean beating people over the head with the AAP guidelines (believe me, I’ve tried it and the guidelines just aren’t thick enough).

If we are to enlist the support of families, nurses, learners, respiratory therapists, and other physicians in doing what’s best for the patient, then we must make this work much in the same way that we get others around us change behavior. Think about the PCP who must impact obesity in the family or vaccine distrust. We have to build relationships based on trust. We must elicit others’ goals and describe ours as a shared agenda. Similarly, we need input from everyone around us as to how to move forward. There are far too many humans involved for this to work without constant attention to creating a well-functioning team.

This will not be an easy task, which is perhaps why moving to Montana or a deserted island seems so much easier. But anytime medicine involves more than just one person, there will be a need to communicate effectively. This becomes critically important as the amount of gray regarding risks and benefits increases.

More is less. Less is more. Our patients deserve that we dedicate ourselves to providing them the best possible care.

Dr. Shen is The Hospitalist’s pediatric editor and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

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