Monday, June 24, 2013

Why Doctors Believe Weird Things: How pediatricians embrace superstition and magical beliefs



(This is an excerpt from my book, Suffer the Children)
 
All men are liable to error; and most men are, in many points, by passion or interest, under temptation to it.
John Locke

A wise man proportions his belief to the evidence.
David Hume

The history of the progress of the human mind is a history of a struggle with its delusions.
Sir William Osler

A few summers ago I had the pleasure of visiting the beautiful northeastern Italian region of Val D’Aosta, nestled at the feet of Mont Blanc on the border with France.  One evening, after a particularly scrumptious dinner, we were invited to the 19th century villa of a dentist, whose sons worked with one of my brothers at the time.  As we sat on the stone veranda, enjoying the cool mountain air, the conversation turned to differences between Italian and American dental practices.
Our host first surprised me by saying that orthodontic appliances are over-utilized in the United States and, in some individuals, can result in harm.  I remain ignorant on this subject and, though it was a novel idea to me, I had no reason to dispute the claim.  Next, he brought up the issue of silver dental fillings (or amalgams) which he considered a significant health hazard due to mercury poisoning.  This I immediately recognized as a pseudo-scientific idea that is well outside the mainstream opinion in dentistry.  I was put on edge, anticipating the possibility that our host might cling to other unusual beliefs.  He did.  He wished to display how his youngest of two sons was allergic to milk.
He brought out a carton of milk from the kitchen, and after a moment’s hesitation, apparently to add a touch of suspense to the demonstration, he handed it to his 22 year old son who was sitting on a patio chair.  Almost immediately the young man’s fit and muscular frame crumpled, and, as his father pointed out, the arm not holding the carton of milk was limp and weak.  I immediately recognized this as a demonstration of Applied Kinesiology: an unproven belief system often employed by naturopaths and chiropractors, that uses muscle testing to diagnose presumed allergies and nutrient deficiencies.
At this point, I asked if I could perform a test of my own.  The dentist eagerly complied.  I went to the kitchen with the carton of milk where I was able to find, with the aid of his wife, two small, dark ochre glass vials.  I filled these vials and returned to the patio.  After receiving assurance from my host that the “allergy” symptoms would be evident even through glass, I asked his son to tell me, based on his symptoms, which of the two vials contained the milk and which one was filled with water.  After a minute of alternately holding one vial, then the other, he confidently asserted that the one on the left rendered him weak, while the one on the right did not. 
Actually, both vials contained milk.  When the young man was blinded as to whether a vial contained milk or not, his cataplexy seemingly resolved.  Alternatively, I could have filled both vials with water to see if weakness might have been elicited by the mere thought that a vial contained milk.  I might be criticized for having employed deception in my test, but had I indeed filled one vial with milk, the other with water, my subject would have had a 50% likelihood of guessing which one contained the milk by pure chance.  I would therefore have had to do repeated tests and compare the results to those expected by mere chance: a bit tedious for an after-dinner rendezvous.
 The dentist found this interesting, but concluded that his son’s allergies must be improving with the treatment that he is being provided, even though just minutes earlier he gave us a dramatic demonstration of the severity of his symptoms.  And if one opaque vial filled with milk caused weakness, logic mandates that the other one must have as well.  But that was not the case.
*****
Doctors, like all humans, are vulnerable to forming irrational beliefs; lending more credence to gut feelings than available evidence, making non-existent associations of cause and effect, falling prey to preconceived biases, and sometimes, engaging in outright superstition: a belief that there are occurrences that cannot be explained by the laws of nature, that are influenced by magical or supernatural forces.
In medical school, in an attempt to boost our performance on exams, many of us utilized amulets or good luck charms.  A published survey of medical students from Basel, Switzerland revealed that 10% of medical students admitted taking good luck charms to their first exam in the medical curriculum.  Other students adhere to inane rituals involving peculiar diets, preferred items of clothing and favorite study locations that have no connection to the actual mastering of the material being studied.
In residency, superstitious beliefs are even more prevalent.  Newly minted physicians are quickly categorized into two groups:  white clouds and black clouds, with the latter group comprised of individuals who seem to be jinxed, having the busiest nights on call, invariably forced to tend to patients who seem to have the worst complications while on their watch.  Understand that this is not viewed as a set of work habits and traits possessed by the individual that makes him more prone to encounter difficulties (as is clearly the case sometimes) but rather the result of an unalterable fate; a type of cosmic karma. Once branded a white cloud or a black cloud, the designation sticks throughout one’s training, and often, many years into practice.
In one survey, 22% of residents admitted to being superstitious in general (which the authors defined as firmly holding beliefs in the absence of objective evidence), 32% had developed belief systems about their nights on call, and 65% subscribed to the belief that some residents are “black clouds”.  A variety of ideas were commonly shared:  that weather patterns can affect how busy one’s night on call is, as does a full moon; that the word “quiet” must never be uttered, as certain words or actions may spark  the ire of “vaguely defined call gods”.  Interestingly, or dismayingly, some of these beliefs intensified through the years of training.
Check out my new medical suspense:
 The Art of Forgetting
Superstition is a way to deal with uncertainty, especially when one senses a lack of control over one’s environment.  It is witnessed in competitive athletes as well as in soldiers deployed to the battlefront; settings that share features in common with the experiences of medical students and residents: a high level of competition, stress, fatigue, and sleep deprivation.
Although the beliefs discussed so far can be viewed as innocent if fatuous notions, of no consequence to the actual practice of medicine, they betray a surprising lack of skepticism for such highly learned individuals.  This ease with which physicians believe dubious ideas exposes a pliability in their thought processes that inclines them to accepting unproven axioms that do have a direct effect on patient care.  Often, what we physicians presume to be scientifically validated precepts are actually a hodge-podge of folklore and myth, passed from one generation of physicians to the next, peppered with untruths, promulgated by questionable sources such as the cleverly edited script of a pharmaceutical representative.
Doctors are not gullible, nor are they eager to be the first to try a new treatment with little deliberation; in fact many among our ranks are outright conservatives, reluctant to revisit, not to mention change, any aspect of our practice.  Yet many doctors base treatment decisions not on available evidence, but on fickle criteria: following the advice of drug company representatives that call on them with free samples, mimicking what other physicians in their group or community are doing, or by simply proclaiming, “That’s how we did it in Chicago when I was a resident”.  Physicians should be able to research the medical literature and evaluate the quality of information available to choose the best way to manage a particular condition.  But many physicians either neglect to do so, or they lack the skill to synthesize data into a workable approach.

Learning Science Versus Thinking like a Scientist
When I was applying to medical school as an undergraduate student, I asked one of my favorite professors for a letter of recommendation.  I was surprised to find he was disappointed with my career choice.
“Why would you want to be a doctor and work as a glorified technician when you could be a scientist?” he asked me.  I was taken aback.  Doctors as mere technicians?  Medicine was science, I insisted.  After all I had to master Physics, Chemistry, Organic Chemistry, Biochemistry and Physiology just to become a candidate for medical school.  It was only years later, when I was already in practice (and I had read Sinclair Lewis’ novel, Arrowsmith) that I understood and grudgingly acknowledged the basic truth of my professor’s assertion.  The point is rendered limpid by the words of Carl Sagan taken from an interview with Charlie Rose: “Science is more than a body of knowledge; it’s a way of thinking, a way of skeptically interrogating the universe with a fine understanding of human fallibility.” 
This way of thinking is lacking in the average general practitioner who in addition, is too often oblivious to his human fallibility.  There is the distinct risk among us physicians to abandon thinking altogether in favor of a cookbook approach to delivering care, incorporating bizarre ideas along the way, adopting a self-congratulatory smugness as we claim expertise when none is present, becoming unjustifiably arrogant in the process.  To understand how this is possible we must start with a glimpse at the long and arduous training process that aspiring doctors must undertake to earn their degrees and allow them to become fully licensed.
*****
Traditionally, medical school is divided into two parts.  The first two years are heavily weighted towards classroom learning of basic science subjects such as Anatomy, Biochemistry, Physiology, Pharmacology, and Pathology, while the last two years are spent in hospital clerkships, at the bedside, refining the skills of taking medical histories from patients, performing physical exams, presenting information in an organized fashion to other team members, and mastering a variety of medical procedures, such as venipuncture, intravenous catheter insertion, placement of naso-gastric tubes, even scrubbing in for surgery.  Though of late most medical schools have introduced clinical coursework earlier in the curriculum, for the most part the basic structure remains unaltered.
The amount of material, the sheer number of bits of information that has to be assimilated in those first two years in order to pass standardized exams, is overwhelming. One of my classmates put it best when he said that medical school was like trying to take a drink of water from a wide open fire hydrant.  Frequently, a professor, wanting to stress the unique importance of a concept she is about to teach, will say, “You will only retain 5% of what you learn in medical school, and this is part of the 5% you can’t afford to forget.”
So how do medical students manage to soak up the ocean of information they are expected to retain, at least long enough to pass their exams, with their puny sponges of gray matter?  Often they resort to shortcuts, tricks and mnemonics, many made more memorable by their sexually explicit nature.  I still remember the twelve cranial nerves by reciting: “On Old Olympus Towering Tops A Finn And German Viewed Some Hops”. When I first used the mnemonic, however, I had particular difficulty remembering the tenth cranial nerve, the Vagus, because I would mistakenly replace “Viewed” with “Brewed”; a seemingly more logical activity for a German to embark in with hops.
Likewise, to remember whether a particular cranial nerve has only sensory function (S), motor function (M), or both (B), I still employ the mnemonic: “Some Say Marry Money But My Brother Says Big Boobs Matter Most”.  A good trick, a particularly memorable mnemonic device, is a hot commodity in medical school because it creates reliable scaffolding onto which one can pile information quickly and for the long term.  And speed is of the essence in medical school:  we must memorize so much information that we don’t have the time or inclination to question the validity of what we learn.
This attitude carries on with even greater urgency in residency.  Now we must know things not for exam purposes, but in order to provide appropriate care to patients, particularly when we find ourselves relatively isolated on our nights on call.  To some degree the internet now provides residents with a wealth of information at their fingertips, without having to stuff the pockets of their white coats with medical reference books, but there is still a hunger for learning simple algorithms to buoy us in our ocean of uncertainty.  And the proximate source of these algorithms is inevitably a more senior resident, who in turn learned a particular pearl from his senior residents, with tenets being passed from generation to generation, with hardly a trace of the original source.  This is thankfully balanced by exposure to dedicated academic physicians, true role models, who engage residents and stimulate critical thinking using a Socratic method of discourse and bedside demonstrations of proper interviewing and examination techniques.
Gradually, despite the deficiencies in their training, many Pediatric residents, through experience and study, mature into competent practitioners, able to embark on their life-long commitment to learning and perfecting their craft.   But if they pursue a typical private practice position they may find that their training leaned far too heavily towards tertiary care leaving large lacunae in their knowledge of primary care issues.  Paradoxically, a pediatrician who has just finished residency may feel more comfortable providing care to a child hospitalized with a perforated appendix than answering a mother’s questions about the timing of introduction of solid foods.  The entire process is akin to training bus drivers by having them fly Boeing-747 jumbo jets.
As doctors are separated from their training by geographic distance and the passage of years, no longer constrained in their actions by the supervising eye of attending physicians, some start toying with creative, if questionable, approaches (creativity is a dubious virtue for a physician). Never having fully embraced the necessarily skeptic and disciplined stance typical of science, they become vulnerable to unproven claims, myths and, in extreme cases, pseudo-science. Some doctors start believing all manner of bunk:  that child obesity is due to vitamin deficiencies; that almost all human illness is caused by insufficient levels of HDL (high density lipo-protein) cholesterol; and that immunizing children is more harmful than beneficial.  They start making sweeping generalizations based on the flimsiest experience, turning a blind eye to tangible evidence. 
They are encouraged in proffering advice on matters of which they are ignorant believing to be guided by a well-grounded common sense.  But as Albert Einstein pointed out, “Common sense is the collection of prejudices acquired by age eighteen”.  Some things in medicine are counter-intuitive.  Before advising we should confirm that our intuitions are correct with research and study.
White Coat Phobia:
It is time to analyze some of the most common misconceptions among pediatricians, starting with a rather trivial question, “What should I wear?”  Many Pediatricians have shed their white coats for more comfortable and relaxed attire.  After all, kids are scared of white coats, right?  Well, not so fast.  There are a few studies evaluating the perception that patients have of physicians based on their attire.  Overall, most patients have a more positive impression of the physician in the traditional white smock.
A couple of studies specifically looked at children’s impression of physicians wearing different clothing.  One study showed that physicians wearing white coats were more likely to be rated as competent by children.  Those dressed casually were more likely to be regarded as friendly, but not competent.  Another study had children and parents rate pairs of photographs of physicians in different poses (standing versus stooping, smiling versus stern expression) and wearing different forms of attire.  The smiling doctors were preferred over the stern ones by both parents and children; however, 54% of children preferred the ones wearing white coats over the ones in casual dress, compared to only 35% of parents (parents have bought into this myth, likely affecting their preference).  So the lesson to be learned is that if we want to be perceived as competent, yet caring, we should wear white coats and smile, and if you prefer not to don the white coat, realize that you are not doing it for the child’s benefit.  The worst faux-pas, from a patient’s perspective and a stylistic one as well, was to wear sneakers.
I admit that the issue of apparel is petty but I use it to exemplify the fact that almost no one questions the misconception that children are scared of white coats:  it is a belief that is accepted prima facie.  Kids may be scared in doctors’ offices and hospitals to be sure:  they are often threatening, unwelcoming places where uncomfortable, if not outright painful procedures take place.  They may very well be even more frightened when the doctor enters the room, but the fear has little to do with the doctor’s white coat.

Formula Follies:
To the neophyte, newborn babies appear to have a limited repertoire of behavior: they sleep, they cry, they eat, they pass what they just ate.  Whenever there is a perturbation in what parents perceive to be the customary behavior for the baby, the usual suspect is the milk being fed to it.
Despite efforts by many health organizations to encourage breast-feeding, many families continue to choose infant formulas as the primary source of nutrition for their newborns.  Formulas are frequently blamed by parents for a wide variety of symptoms such as fussiness, gas, regurgitation, and changes in the frequency, consistency, color and smell of stool.  Though true cow’s milk protein allergy (the most common bona fide type of milk intolerance in infancy)  has been shown to exist in less than 6% of the population, in some practices as many as 30% of formula-fed infants are switched to expensive hypoallergenic formulas.
In the past, the most common myth surrounding formulas was the belief that iron was responsible for constipation and other problems with defecation.  Many infants were inappropriately fed low iron formulas, placing them at risk for iron deficiency and its many complications (Iron is an important nutrient for the developing brain).  Most pediatricians have fortunately abandoned this practice though new acts have taken its place.
A little over a decade ago, it became vastly popular to utilize cow’s milk based formulas that were enzymatically treated to remove (or at least reduce) the sugar, lactose.  I remember having a conversation with a representative of a large formula manufacturer who tried to persuade me that lactose intolerance was the most common feeding problem in infancy.  When I argued that he was grossly mistaken and provided him with actual statistics he quickly changed the subject, yet his efforts, and those of his colleagues were hugely successful in promoting these unnecessary formulas.  Within a year or two, an inordinate number of infants (some 30% of market share in my community in South Texas) were being fed the milk he was promoting. Even now, I hear many parents report the fallacy that their infant was diagnosed with “lactose intolerance”.
In newborn nurseries, infants are switched from standard formulas to lactose-free formula, often on the first day of life, if the baby happens to spit up on a single occasion – an event that should hardly surprise anyone.  In other instances the formula is being used to mitigate constipation, and, with many families I care for, the parents haven’t a clue as to why the baby is on a lactose-free formula. The most baffling practice, one that I’ve witnessed repeatedly, is that of feeding infants breast milk (which contains lactose) while, at the same time, supplementing with a lactose-free formula.
Lactose is a disaccharide: it is composed of two simple sugars, glucose and galactose, which are linked together by a single molecular bond.  In order for these simple sugars to be absorbed by the lining of the intestine, to then be utilized by the body, this molecular bond must be cleaved in two by the enzyme, “lactase” which is located on the surface of the intestine in a specialized area called the brush border.  An enzyme is a protein that helps to promote a specific chemical reaction in the body.  The names of enzymes can be easily recognized by the suffix, “-ase”.  It is interesting to note that the only place in nature where the sugar lactose is found is mammalian milk, and baby mammals, including baby humans, are exquisitely equipped to digest lactose with only remarkably rare exceptions.
These exceptions include Congenital Lactase Deficiency and Secondary Disaccharidase Deficiency.  Congenital Lactase Deficiency occurs when a baby inherits two abnormal copies, one from each parent, of the gene for lactase, which is located on Chromosome number 2 in humans.  This results in a markedly decreased ability to synthesize the enzyme, causing newborns to develop severe diarrhea which leads to dehydration, metabolic abnormalities and almost certain death, unless the lactose is removed from the diet.  Fortunately, this condition is extremely rare.  In one series of more than 1,600 small intestine biopsies obtained in infants suspected of having this condition, the diagnosis was confirmed in only one case.  The average pediatrician, with 2,000 to 3,000 children in her practice at any one time, is unlikely to care for a single child with this disease in her career.
Secondary Disaccharidase Deficiency is far more common but is usually a temporary condition.  It results in insufficient levels of the enzyme lactase due to injury to the brush border of the intestine as a result of illness (most typically prolonged diarrhea) or surgery.  Some infants with Secondary Disaccharidase Deficiency may need a temporary reprieve from lactose-containing milk until they are able to build up adequate levels of lactase in their brush border.  Soy formulas, which are naturally free of lactose, are successfully used in this setting.
For the sake of completeness I will briefly mention yet another condition that results in severe diarrhea and bloating due to the inability to absorb milk sugar, but in this case, removing lactose does not lead to resolution of the symptoms.  Glucose-Galactose Malabsorption is a life-threatening disease in which the cells lining the intestine are unable to take in the simple sugars, glucose and galactose.  This condition is so rare that only a few hundred cases have been identified worldwide.  As you may have surmised, a formula where the lactose is artificially cleaved into its two components cannot be fed to these infants.
Much of the misunderstanding surrounding lactose intolerance in infants comes from the fact that the majority of adults, nearly 4 billion people worldwide by some estimates, are unable to digest lactose, though not all are symptomatic.  Most mammals nurse their young until the baby is around three times its birth weight.  In humans this corresponds to about one year of age.  In most individuals, the production of the enzyme lactase starts to decline at about two years of age, yet symptoms of acquired lactose intolerance rarely develop before age six or seven.  If adult members of the family have problems with lactose intolerance, the natural perception is that the progeny must have acquired the same trait; and they probably have, though the symptoms should not be apparent during infancy.  The widespread popularity of lactose-free formulas cannot be explained by our knowledge of physiology, genetics and nutrition, and one can only conclude that it is a result of faulty reasoning.
Formula manufacturers prey on these misconceptions, trying to gain market share and maximizing profits by promoting “special formulas” in settings where there is no recognized medical indication for their use.  One strategy is to attach meaningless labels such as “gentle” or “sensitive” to the names of formulas that are not truly hypoallergenic.  Yet another is to try to persuade parents to purchase expensive hypoallergenic formulas to soothe colic symptoms, even though our current understanding is that colic is not due to digestive issues.  Many physicians become the unwitting accomplices in this charade, recommending formula changes at the drop of a hat instead of attempting to understand parental concerns, deciding whether reported symptoms are normal variants of infantile behavior, and thinking logically about nutritional choices in infancy.

Diagnostic Fetishes:
Occasionally, some doctors develop pet theories that may contain a tiny kernel of truth, but are over-generalized and misapplied.  I already alluded to a physician I know of who thinks that all illnesses, from septic shock to behavioral disorders, are due to low levels of HDL, also known as the “good cholesterol”.  For almost every medical condition, he advocates treatment with high doses of Niacin. Though HDL has been shown to be relatively protective when it comes to the development of heart disease, and may be a factor in the development of sepsis in critically ill patients, many of the claims of this colleague are a bit of a stretch. 
When doctors adopt a pet disease, they apply the most inclusive criteria to make the diagnosis, so that soon any collection of symptoms can be seen as evidence of the condition.  If you make a slot large enough, you can fit pegs of any shape through it. 
One of my previous partners was obsessed with gastro-esophageal reflux in infants.  GE reflux, as it is often referred to, is an extremely common phenomenon in babies, as it simply implies that food that is ingested and reaches the stomach is occasionally regurgitated back up the esophagus, and sometimes, as any parent has had the opportunity to witness, back out of the mouth.  But effortless regurgitation is not necessarily pathologic.  It can be demonstrated in virtually all newborns at some time or another if one employs specialized tests.  More than a disease, it represents incomplete development of the complex neural circuitry involved in keeping food going one way, down-stream in the intestinal tract.  By the age of six months, many infants stop spitting up, and almost all do by the age of one year.
There are some babies whose regurgitation is frequent and severe enough to affect their growth, cause respiratory problems, or manifest other symptoms such as fussiness and unusual posturing.  Some of these children have recognizable underlying neurologic conditions such as cerebral palsy.  In this case the condition is referred to as Gastro Esophageal Reflux Disease (GERD).  It is important to make the distinction between the nearly universal GER and the rare GERD: the latter is a disease, the former is not.  The treatment for infants with GER may include simple reassurance, providing smaller more frequent feedings, and occasionally thickening of the feedings.  On the other hand, babies with GERD typically need medications to reduce the acidity of the stomach or to promote the forward movement of food down the alimentary canal. In some cases they may even require surgery.
In 1999, my partner had most of the infants in her practice on one or more anti-reflux medications.  Though some of these medications are generally safe – particularly those used to reduce the acidity of the stomach – others have troublesome side-effects.  Some of her patients were taking cocktails of drugs that included Bethanecol; a drug often used to treat urinary incontinence in adults but seldom used in infants.  One of the medications she most frequently employed, even in babies with minimal symptoms, was Cisapride: perhaps the most effective drug available for the treatment of reflux, but with a potentially lethal side-effect.  Earlier in the year all prescribing physicians, including my partner, received a letter from the manufacturer of the drug warning that some infants taking Cisapride had died due to irregular heart rhythms. Nonetheless she continued prescribing the medication without a moment’s hesitation to a large proportion of her patients under the age of 12 months. Then my partner unexpectedly left the practice, and I inherited many of her patients.   
Over the following months I re-evaluated dozens of infants that were taking medications for GE reflux, none of whom, in my opinion, required treatment with pharmaceuticals.  I stopped the medications, sometimes to the consternation of the parents, who by now were convinced that their children had a serious illness. Some parents left the practice to find a doctor who would continue refilling the Cisapride prescriptions when I refused to.  Then, on July 14, 2000, Cisapride was voluntarily recalled from the United States market as a result of persistent concerns over its safety.  For weeks I received a deluge of phone calls from worried parents, including some who were originally resistant to the idea of discontinuing the use of the medication, now baffled by the decision to use it in the first place.
Years later, I worked with another partner who prescribed the drug Cholestyramine to all his patients that presented with diarrhea.  Cholestyramine is a drug that binds to bile acids in the intestine, preventing their reabsorption, thus aiding in their excretion.  It is most frequently used for the treatment of high cholesterol.  There is some basis to employ it in the treatment of diarrhea under limited circumstances:  when the diarrhea is compounded by the presence of unbound bile acids in the intestine, such as when the portion of the gut that normally absorbs bile acids is surgically resected.  But the diarrhea we most often encounter in children is not due to malabsorption of bile acids, but to secretion of fluid by the intestinal lining as a result of a viral infection.  The use of Cholestyramine to treat childhood diarrhea is not only ineffective; it is highly illogical.  But there was no convincing my partner who had found his pet treatment.  Here was a prescription he could write, something he could do, and his patients were getting better after all.  They would have even without the medicine.

Of Warblers and Doctors:
Most doctors develop habits in their approach to patients and preferences in the medications they prescribe that is customarily referred to as their “practice style”.   When I worked as a pediatric hospitalist, being referred patients for hospitalization from throughout the community, my colleagues and I were often able to recognize the doctors who had previously seen a particular patient by the treatment that had been provided; a skill I likened to the ability a birdwatcher has in distinguishing the mating call of the Northern Mockingbird from that of the Gray Catbird. 
A child was prescribed oral Albuterol to soothe a cough along with a syrup containing dextromethorphan?  Why, that’s the unmistakable song of the doctor who works at the clinic down the street.  A playful toddler presents with the diagnosis of “occult bacteremia” due to an elevated white blood cell count?  Well, well; this could be any of a number of birds, but wait, the child was given an intramuscular injection of Cefotaxime in the office prior to being sent to the hospital.  That little inflection in the song is quite specific for the warbler that runs the Medicaid mill just outside of town.  The bird call game lost all its charm when, instead of a curious sounding chirp, the noise reaching our ears was a distinctive, honking quack.
That there are differences in practice style among physicians which can be supported by evidence is understandable, as quite often there is no single clearly preferable approach to a problem.  One can argue that these variations are even desirable.  What is unjustifiable is the embracing of a favorite treatment that encourages the over-diagnosing of a particular condition, placing the cart in front of the horse, so to speak.  As the saying goes, when all you have is a hammer, everything starts looking like a nail.
*****
America has a long tradition of dubious pediatric advice.  In the 1920’s, American child-rearing philosophy was strongly influenced by Dr. John B. Watson, considered by many the father of behavioral psychology, whose book, Psychological Care of Infant and Child recommended mothers use the following approach towards their children:  “Never hug and kiss them.  Never let them sit on your lap.  If you must, kiss them once on the forehead when they say good night.  Shake hands with them in the morning.  Give them a pat on the head if they have made an extraordinary job of a difficult task.”
To further discourage demonstrations of affection he admonished, “Won’t you then remember when you are tempted to pet your child that mother love is a dangerous instrument?  An instrument which may inflict a never healing wound, a wound which may make infancy unhappy, adolescence a nightmare, an instrument which may wreck your adult son or daughter’s vocational future and their chances for marital happiness?”  More than half a century later, Watson’s granddaughter, the actress Mariette Hartley, would blame the practical application of her grandfather’s theories for the family dysfunction that contributed to her life-long struggles with psychological challenges.
It is easy to scoff at Dr. Watson’s stern warnings, dismissing them as symptomatic of a less illuminated era, until we analyze the quality of pediatric advice that continues to be dispensed.  Recently, Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at the Steven and Alexandra Cohen Children’s Medical Center of New York sent a survey, called the Pediatric Health Beliefs Questionnaire, to a sample of board-certified pediatricians.He found that thousands of pediatricians still subscribe to popular parenting myths and false beliefs.  More worrisome, 76% endorsed one or more practices that could pose a significant health hazard to children.   More than 1/3 of pediatricians mistakenly believed 8 out of 40 pediatric myths presented to them.
One symptom that is of particular concern to parents, and is thus not surprisingly associated with a myriad of myths, is fever.  In fact, the fear of fever, which is often accentuated by dramatic portrayals in the popular media, is so intense in some cases that it has been dubbed “fever-phobia”.  A practice that has become almost universal in the pediatric community is that of alternating the fever reducing medications, Acetaminophen and Ibuprofen (using a variety of dosing schedules) in an attempt to suppress fever more completely.
In a published survey of 161 pediatricians, half of the respondents stated that they routinely advised alternating Acetaminophen with Ibuprofen for fever control.  When asked the basis for this advice, 29% said they were following recommendations from the American Academy of Pediatrics.  A puzzling statistic, seeing as the American Academy of Pediatrics does not have a policy that recommends this practice.
There are several problems with using both medications in conjunction as a routine for fever control.  The inconsistency of the schedules employed can easily lead to dosage errors with possible overdosing.  Published reports have illustrated the potential for some children to develop reversible kidney failure when both medications are used.  Furthermore, there is the unintended side-effect of increasing parental anxiety with such an aggressive approach.  If the doctor is so keen on eliminating fever, after all, it must be quite dangerous.
Instead, fever is a potentially beneficial mechanism, an important part of our immune system’s response to infection, the product of millions of years of evolution.  Even cold-blooded animals (scientifically referred to as poikilotherms, from the Greek roots “poikilo”, meaning varied, and “therm”, heat), such as reptiles, amphibians, fish, and even worms, will produce, in response to infection, what is known as behavioral fever. They raise their body temperature, not through a complex interplay involving the production of hormones and other chemicals as is typical in mammals, but by moving into a warmer environment: a lizard may lay on a stone heated by the sun, while a fish will swim to warmer water.
Regular use of fever suppressing medications, also known as antipyretics, may prolong illness in individuals infected with influenza A and other infections.  In animal models, use of these medications is associated with more severe organ damage and higher mortality with a range of infections. So why treat fever at all?  Simply put, fever is uncomfortable.  It is often accompanied by headache, body aches, fatigue, lethargy and lack of appetite.  The goal of using these medications in children should not be the quashing of even the slightest elevation in temperature, but to provide comfort.  This can be easily accomplished with the use of just one medication.
Yet, the advice to alternate medications has become nearly universal despite the fact that there is precious little evidence to support it.  Several published analyses of available data have discouraged this practice.  But it is wrong to think that doctors and nurses choose to ignore these warnings:  the truth is they are completely unaware of them.  They are utterly convinced that what they are recommending is the standard of care, without ever questioning the origin of this practice or its validity.  As is so often the case, there is a huge gulch separating available knowledge and current practices.

Forcing the Tissue:
Another frequent source of parental confusion and apprehension, the direct result of poor advice from professionals, is the handling of the intact foreskin in uncircumcised boys.  This confusion and insecurity leads many parents to opt for circumcision outside of the newborn period to mitigate perceived problems.  Many doctors persist in wrongly urging parents to forcibly pull back the foreskin in infants, even chastising them for not doing so more aggressively and cruelly blaming them for any problems that occur as a direct result of their own bad counsel.  But as anyone who has examined an uncircumcised newborn can plainly see, it is impossible to retract the foreskin of a baby without causing pain and injury.
Most medical school curricula include precious little when it comes to the normal anatomy of the prepuce, so it should be no surprise that there is a fair amount of ignorance among physicians when it comes to this subject.  Our understanding of the anatomy and physiology of the foreskin was advanced by a sentinel article by Douglas Gardner, titled “The Fate of the Foreskin”, published in the British Journal of Urology in 1949.  In his study, he found that the foreskin was retractable in only 4% of normal newborns, 20% of six month old boys, and 50% of twelve month old boys.  In uncircumcised boys between the ages of 5 and 13, 6% had a foreskin that could only partially be retracted.  By the teenage years, only 1% of boys have foreskins that do not fully retract.  This illustrates the fact that there is a normal, gradual process of separation between the tip of the penis and the foreskin that occurs at different rates among children.
The condition in which the foreskin cannot be retracted due to the presence of adhesions is known as “physiologic phimosis”.  The word “physiologic” highlights the fact that this is a normal condition.  On the other hand, pathologic phimosis is a condition in which the foreskin cannot be retracted due to the presence of an abnormal fibrous ring around the tip of the foreskin; the product of scarring and loss of elasticity of the tissue.
The forcing apart of normal adhesions in children with physiologic phimosis can result in micro-tears of the prepuce, bleeding and, if repeated with persistence, scarring, with the final result being pathologic phimosis.  Furthermore, forcibly retracting a foreskin with a small opening can result in the foreskin remaining trapped behind the head of the penis, compromising the blood supply to its tip; a medical emergency known as paraphimosis.
The repeated forcing back of a tight foreskin is an exercise in futility that is furthermore, completely unnecessary.  Adhesions will promptly form again even when temporarily torn apart, whereas, if left alone, over time the inside lining of the foreskin undergoes a process known as squamous metaplasia. Cells slough from the inner lining of the foreskin, the tissue becoming less sticky, and a preputial space is created, separating the two tissues laying in direct apposition.  At the same time, the opening of the prepuce stretches and enlarges, with the help of tension provided by erections and gentle manipulation, allowing full retraction to occur safely and painlessly.
The advice by doctors to forcibly retract the foreskin of babes in the hope of avoiding pathologic phimosis leads to a self-fulfilling prophecy.  Though there are plenty of scholarly articles and position papers on this topic warning of the potential harm of using force to push back the foreskin, physicians continue to recommend this fallacious and cruel act, with many children being referred for circumcision for a normal condition.

An Alternate Universe of Pediatrics:
There are countless other circumstances in which the actual practice of medicine bears little resemblance to what is regarded as the standard of care.  It is as if an alternate universe exists; one where principles obtained through scientific rigor are ignored in favor of a new reality whose only proof is its popularity.  Interventions develop a veneer of propriety simply through their repetition. Gradually foolishness attains respectability. Unfounded ideas propagate, spreading from the mind of one host to another, seemingly achieving a life of their own.
The concept that ideas can replicate much in the way that genes do, and be transmitted throughout a culture, competing for their survival in a manner analogous to Darwinian evolution, was popularized by the British evolutionary biologist Richard Dawkins in his book, The Selfish Gene.  A unit of cultural idea, according to this theory, is referred to as a “meme”, and a new field of study, known as “memetics”, has been created.  The nascent theory certainly has its shortfalls and its critics, yet it provides a useful framework for understanding how beliefs take hold in a culture.  In the culture of Pediatrics, one can easily envision how certain hosts, possessing specific personality and psychological traits, and located in strategic practice locations, can spread an idea to others (shall I dare say, infect?) in a particularly effective way.  Absurdity becomes epidemic.

Hardwired fallibility:
Though most people would like to think of themselves as objective, rational and logical, the way we come to embrace and hold onto certain opinions demonstrates that we are far from that.  This has little to do with innate intelligence; in fact highly intelligent individuals may be more skilled at rationalizing and defending an invalid point of view.  Rather, it is a reflection of our human fallibility; the consequence of recognizable psychological mechanisms, of fallacies in information processing, that can wreak havoc with the development of strongly held beliefs.
Our brains are constantly bombarded with information originating from our five senses.  They must process, analyze and interpret this information, before deciding what type of reaction is appropriate on our part.  There is a limit to the amount of information our brains can handle at one time, dictated by the number of brain cells (also known as neurons) available to perform a task, the number of connections between different groups of neurons, and the speed by which impulses are able to travel the length of a cell and across the gulches between neurons known as synapses.  Thus, the brain has evolved a repertoire of tricks and shortcuts to provide us with an adequate, though imprecise, representation of our world.
We are not consciously aware of the blind spots created by the optic nerve of each eye leaving the retina because the brain fudges a little and fills in the gap with a useful, if inaccurate, approximation.  We don’t require a pixel by pixel analysis of the image of a mountain lion crouched on a rock in order for our brains to immediately recognize danger and activate the fight or flight response.  Our brains need just recognize certain salient features to recognize a pattern.  This capacity for pattern recognition has undoubtedly provided our ancestors with a survival advantage: the sooner you are aware of that mountain lion on the rock overhead, the more likely you are to escape with your life.
 This capacity for rapid identification, however, can make us recognize patterns that are not really present.  We identify figures in clouds drifting overhead, and we perceive human faces (frequently that of Jesus, the Virgin Mary, or Elvis) in a stain on a wall, in the wood grain of a door or even on a grilled cheese sandwich.Likewise, in witnessing a series of events we can convince ourselves that there is a pattern where none exists.  We can associate events that occur simultaneously or in rapid succession, convincing ourselves that there is a cause and effect relationship.  Quickly we formulate a rule or law that describes this pattern.  After all, such a rule may aid in quickly reaching an important decision in the future.  It would be apropos at this point to try to categorize some of the common fallacies that humans fall prey to in formulating erroneous beliefs.

Bias:
The word “bias” is sometimes used synonymously with “prejudice” and almost always carries a negative connotation.  For the purposes of our discussion it will specifically refer to a tendency or predisposition to believe a particular explanation of observed phenomena.   Biases are a sort of shorthand of the mind in an attempt to make sense of events surrounding us.  In that sense they can be thought of as the most rudimentary and crude formulation of a hypothesis.
The generation of ideas and hypotheses is a valuable skill; one that humans are particularly good at.  Problems arise, however, when our tentative hypotheses are not questioned, scrutinized and tested more thoroughly.  The inherent problem with bias is how we go about handling additional information.  The tendency is to give more weight to information that confirms our preconceived notions, and to dismiss contradictory information, reasoning that it is either flawed or not relevant to the case in point.  In the same vein, we tend to remember events that confirm our viewpoints better than we can those that dispute them.  This phenomenon is referred to as “confirmation bias”.
The success of science in explaining natural phenomena has been its cognizance of our tendency towards bias, and its attempt to eliminate it by adhering to a set of formal procedures that includes testing hypotheses under controlled conditions, confirming observations by attempting to replicate them, and the adoption of a rigorously skeptical approach.  One must be ever vigilant for attempts to couch untested theories in the language of science.  This approach, best defined as “pseudoscience”, borrows scientific principles, often employing them in an allegorical or metaphorical way, misapplying and misconstruing them, to support their fallacious assumptions.
Thus we hear about Candidiasis Hypersensitivity Syndrome, Chelation therapy for behavioral problems and Quantum healing, as practitioners attempt to blur the distinction between science and nonsensical speculation.  As we have seen, individuals with a Medical degree are apt to fall for this approach as well, if not by embracing a particular form of pseudo-science, by adopting pet theories that they do not submit to the necessary process of skeptical scrutiny.
It may be impossible to eliminate bias altogether if it is a cognitive process that is essentially hardwired in our brains.  We must, therefore, at a minimum be aware of our biases and understand how they may sway our perceptions and our decisions.  For example, when it comes to the practice of Pediatrics I am aware of my personal biases:  I believe that most children are intrinsically healthy and the challenge of the Pediatrician is to identify the minority that are not; I believe most of the common problems that bring children to the attention of their doctors tend to resolve without treatment and require at most, only comfort measures; I believe that children should be on the fewest medicines for the shortest period of time, and whenever possible, should take no medications at all; and I believe that every medical encounter is as likely to produce harm as it is to generate a beneficial outcome.  The nature of my biases may expose me to the possibility of erring in the direction of missing an important diagnosis and of not providing necessary treatment to a child that desperately needs it.  By reminding myself of my biases I activate a self-correcting mechanism; a type of damper that I can only hope will restrain me from stumbling into flawed assessments.

Over-generalization:
Generalization is one road to bias and prejudice: forming opinions about many on the experience with a few; an improper form of induction.  In medical practice, hasty generalization can have several effects.  Doctors learn to diagnose diseases, in great part, through a process of pattern recognition.  Though much time may be spent absorbed in books, memorizing lists of symptoms associated with a particular condition, the most vivid lessons are those provided by our experience, caring for a patient with a particular condition.  That patient, seen during our residency, becomes the prototype for that particular disease, helping to remind us of its identifying signs and symptoms.
The problem is that the same disease process can have a variety of presentations and Mr. Jones, whom we remember from our internal medicine clerkship as a fourth year medical student, may not have had a typical presentation for ulcerative colitis.  In the words of Sir William Osler: “We, the doctors, are so fallible, ever beset with the common fatal facility of reaching conclusions from superficial observations, and constantly misled by the ease with which our minds fall into the ruts of one or two experiences”.   Our entire conception of a particular disease may be skewed by our limited experience, helping us fail to recognize it when it presents in a different way. 

The Rooster syndrome:
A child that lives on a farm notices that every day, just before dawn, the rooster crows.  Soon after, the first rays of morning sun begin filtering through the cracks of his window curtain.  He concludes that the crowing of the rooster causes the sun to rise.  This fallacy in logic, also known by its Latin name of post hoc ergo propter hoc (after this, therefore because of this), describes the tendency, when two events happen in succession, to infer that the first event caused the second one to happen.  As a matter of fact, cause and effect do tend to occur in close temporal order, yet often, two unrelated events can occur in succession by coincidence.  Alternatively, two or more events that happen in sequence can be the result of a yet unrecognized cause.
A child is brought to the doctor because he’s had a cough for one week.  The doctor prescribes an antibiotic and asks the family to bring the child back one week later.  At the follow up appointment the child is doing much better.  The doctor credits the antibiotic for the cure. Actually, the child would have gotten better anyway since the cough was due to a self-resolving viral infection. The doctor fell prey to the rooster syndrome.
 The human body’s magnificent self-healing abilities and the tendency of even chronic diseases to have periods where symptoms wane, predispose us to attribute healing properties to all manner of ineffective treatments, both conventional and “alternative”.  Pharmaceutical company representatives, when calling on physicians, are fond of asking how their product is working out for us, in a manner similar, I suppose to that used years ago by salesmen of leeches and patent medicines.  The only way a physician’s personal experience would be reliable and relevant is if it were uniformly negative:  none of the patients improved, or they all suffered a particularly troublesome of disfiguring complication.  To be confident that a treatment has true therapeutic properties, on the other hand, one must insist on objective data in the form of a well-conducted scientific study, where a large number of subjects are randomly assigned to different forms of treatment, and neither the patient nor the doctor know which type of treatment the patient is receiving.
When submitted to this type of scrutiny the results of alternative therapies are routinely disappointing, but so are many “conventional” therapies that were previously thought to be beneficial.  Even some operations once thought to be beneficial, such as the ligation of the internal mammary artery for the treatment of chest pain, when rigorously examined are found to be no better than sham treatments, whose benefits are now recognized to be solely due to the placebo effect: the subjective perception, on the part of the patient, of an improvement in symptoms based on the belief that an effective treatment was rendered.

A Need for simplicity:
Human physiology is extremely complicated, as are the mechanisms with which our bodies respond to disease states and to therapeutic interventions.  A particular outcome may be due to the interplay of many more variables than our minds are able to juggle at the same time.  As a result, doctors resort to wholesale simplification to help them steer their way. This simplification may lead us to neglect important elements, however.  Thus we are navigating fully conscious of the direction of the prevailing wind, aware of the angle of the tiller, but neglecting to consider the size of the sails, the size of the rudder, the strength of the cross currents and the effect of wind shear.
We come to favor a limited number of diagnoses for the majority of the patients we encounter, developing a type of tunnel vision that does not allow us to consider other possibilities.  Fever is immediately ascribed to an infection, and a child may be subjected multiple treatments with antibiotics over a period of months before the correct diagnosis of Juvenile Rheumatoid Arthritis is even considered.  A one month old infant may undergo multiple formula switches before his inexorable deterioration leads to the diagnosis of pyloric stenosis: an obstruction in the outflow tract of the stomach.
Some practitioners skip the step of assigning a diagnosis altogether, opting for an if-then approach of makeshift algorithms.  If the baby is fussy, then give gas relief drops.  If the child has a fever, then get a White Blood Cell count.  If the White Blood Cell count is greater than 15,000, then give an injection of antibiotic.  If a child is anemic, then give iron.  Any of these interventions in specific circumstances may be appropriate (except for the gas drops), but not before even considering the likely diagnosis.  This simplistic strategy is often utilized by less experienced individuals who have yet to develop a more sophisticated understanding of Pediatrics, and are using this leap-frog method to keep from submerging in their lack of knowledge. Among its users are residents, midlevel practitioners, and physicians practicing outside of the scope of their training. All physicians are vulnerable to this tactic when we find that no diagnosis is forthcoming based on pattern recognition.  We are then forced to think systematically, using our knowledge of physiology, anatomy and pathology to propose a list of potential diagnoses – referred to by physicians as the differential diagnosis – before selecting out the most probable of these and determining an approach that will allow us to zero in on the correct choice.  But thinking is such hard work, especially when you have a waiting room full of patients yet to be seen.  It is far easier to just do something, create the illusion of propriety and hope for the best.
*****
If human fallibility makes us vulnerable to being seduced by unfounded beliefs, the antidote is to adopt a scientific stance: to question our pet theories and long-held ideas; to insist on evidence and be wary of arguments weighted on authority; to reject dogma in favor of a skeptical attitude.  Some may find such an approach inflexible, cold, narrow minded and lacking intuition.  They may argue that the scientific approach is only one of many equally valid world views, and there is much that other traditions have to offer.  But at the end of the day, science works in a highly reliable way.  Cellular phones, air conditioning, computers, jet airplanes, satellite radio, and garage door openers all work reliably as a result of an understanding of natural laws, the result of rigorous discipline in the application of the scientific method.  Science may not be able to answer many of the questions that have troubled humans through the millennia, and it may fall short of providing the warmth and comfort that other philosophical approaches purport to offer.  Some may argue that science will never be capable of fulfilling some of our deepest emotional needs.  But whether I’m on an airplane cruising at 500 miles per hour at 35,000 feet, or I’m about to be anesthetized to have my gall bladder taken out, I’ll gladly choose science over any other way of understanding our world.

5 comments:

  1. Thanks for a fascinating post. You have a new reader!

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  2. This is a interesting concept in which results in what they accept in their understandings and the like. Though, for medical science, we do need to look into older yet ancient healing methods. The people weren't stupid and they wouldn't have kept using a method that didn't work for centuries had that been the case. Looking into the other forms of healing science and thus adapting the current definition of science very well could change and increase the effectiveness of modern pediatricians of a Columbia MD and so much more. But doubt, it seems, it what is holding us back.

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  3. I'm actually guilty of believing some dental superstitions, but that was before my Chandler dentist slowly converted me to the methodological way of assessing whether the belief was scientific or just an old wives tale. It helped me look at things in a new light, as not all superstitions are fabricated, just exaggerated.

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