Chiropractic Research on Tourette Syndrome: The Trouble with Case Reports…..

There has always been, and will likely always be, a disconnect between clinical practice and the results of well-designed research trials in the world of alternative medicine.  This has become an increasingly obvious fact over the past several years as alternative medicine has become incorporated into even our top-tier academic medical centers. Proponents of alternative medicine even have their very own government-funded research agency, the National Center for Complementary and Alternative Medicine, which puts over 100 millions dollars to use studying things like energy healing and homeopathy every year. And on a seemingly weekly basis, press releases and credulous news reports emerge with claims of new scientific research proving that believers in these unconventional modalities have been right all along. The curmudgeonly skeptics are often portrayed as  foolish, or worse, closed-minded.

What the vast majority of the patients seeking help from these snake-oil salesman don’t seem to realize, or at least don’t seem to care, is that alternative medicine is a house of cards built upon a foundation consisting of anecdotes, testimonials, cherry picked research practically designed to yield positive results, and the interference of lawmakers. Many physicians, now commonly referred to as “shruggies”, are uninterested in the reality behind alternative medicine and a growing minority actively support it. Naturally there are also a number of well-known celebrity practitioners and supporters of these therapies that serve as spokespersons for the industry. But what is unknown to the shruggies, and ignored or downplayed by the silver-tongued alternative medicine gurus, with their persuasive abilities eerily similar to leaders of religious movements, is that in many cases the definitive studies have been done, the question of efficacy answered. They may claim to integrate the best of both conventional and alternative medicine, but they know where their bread is buttered. So they forge ahead, touting anecdotes and inadequate research as proof. Proof that they don’t even need because their followers don’t really care what science has to say on the subject. Reality takes a backseat to belief.

The most common incursion of alternative medicine into published journals, most of which have impact factors only appreciable with the aid of a high-powered magnification device, is in the form of the case study. A rigorously documented case study can be a valuable thing, even if its place in the hierarchy of evidence is above only the undocumented anecdote and testimonial. They can be especially useful in determining that an all-inclusive assumption is in error, the classic example being that the existence of even one black swan disproves the statement that all swans are white. For an example in the practice of medicine, a single case report documenting Sickle Cell disease in a caucasian child of European ancestry is enough to prove that Sickle Cell disease does not occur only in patients with African ancestry. Case reports can also be helpful, especially in a series, in guiding future research. And in instances of rare conditions, case reports may be all that is available to guide therapy. But a case report, regardless of how well it is documented or of how good a journal it is published in, is incapable of answering the question of cause and effect. They can lead a researcher to a come up with a dandy hypothesis or, as occurs with much higher frequency, to waste time and money on a wild goose chase. A physician simply can’t say that a treatment works based on case reports and, as with personal anecdotes, the whole of the medical literature on a subject must be taken into account.

I was diagnosed with Tourette Syndrome when I was about seven years old. Bear with me, I promise that this isn’t a non sequitur. I have been very lucky in that my Tourette’s, after a rocky few years in middle school and early high school, is fairly mild. It is obvious to most people that I have a movement disorder, but it has never impacted my ability to function in society and to succeed in my chosen profession of pediatric medicine. In fact, I often think of my Tourette’s as a positive aspect of my life, believing that it helped shape who I am as a person. I feel that it helped instill in me positive personality attributes that are beneficial in the practice of medicine, such as empathy and compassion.

I have never needed treatment of any kind for my Tourette’s, but I have tried to keep up with the literature on various therapies, pharmaceutical and otherwise, for the condition. I usually stick to reputable sources but every now and then I like to go “slumming” in the world of chiropractic research. During my last trip across the border between science and pseudoscience, I discovered a gem which perfectly illustrates the trouble with case reports and with chiropractic. I stumbled on a press release for a case report published in late 2009 in the Journal of Pediatric, Maternal & Family Health – Chiropractic involving the year-long treatment of Tourette’s in a 20-year-old female. Not unexpectedly, the results were reported as positive. A quick google search using “chiropractic for Tourette’s” revealed almost 100,000 results, with many (I stopped counting at 100) individual chiropractors referencing this case report when calling for patients with Tourette’s to come in for treatment. They were not equivocal on the subject either but then again practitioners of alternative medicine don’t much care for nuance and subtlety. Warning bells should go off whenever a proposed abnormality, be it the chiropractic subluxation, stagnant chi, or liver flukes, causes every problem and has a ready made solution. So chiropractors are claiming to be able to cure or significantly impact the symptoms of Tourette’s, and this is the proof. Or is it?

The answer is of course no but I’ll explain. Tourette’s is a condition perfectly suited for placebo effects. It waxes and wanes in severity, with many sufferers experiencing periods of time during which their tics aren’t as forceful or frequent. Tourette’s is generally at its peak in early adolescence, or about ten years after diagnosis for most patients, but, and I hope this clearly shows why using such a case report as anything other than for lining your child’s hamster cage is granting it too much importance, two-thirds of Tourette’s patients experience remission or significant amelioration of their tics in late adolescence or early adulthood. The patient described in this case report was 20-years-old and the treatment took place over an entire year. It is very possible, if not highly likely, that the patient’s symptoms would have improved regardless of the therapy she sought out. Not taking into account the natural course of a condition tends to occur when you lack experience in diagnosing and caring for patients with that condition, and when your background in pediatric pathology involves a weekend course held at the airport Howard Johnson. I’d say its a rookie mistake, but chiropractic was invented in 1895.

The tics, whether motor or vocal, simple or complex, experienced by Tourette’s patients are unique. They can be suppressed, for a time, only to come back with a vengeance eventually. They are suggestible. They are effected by stress and by fatigue. And, like pain, there is a considerable subjective component to the movements and outbursts. One patient’s suffering with the condition may be much greater than another’s despite having the same tics in the same location. The potential factors at play are too numerous to list but to give one example, my most obvious tic, where I forcefully jerk my left arm outward and vigorously flex and extend my arm several times until it “feels right” doesn’t bother me when I’m sitting  in bed reading a good book, my bedside lamp safely out of reach. But ask me how I feel when sitting in a crowded movie theater with a stranger on my left who I really don’t want to elbow in the face. Now what if I had a job that required long shifts with close quarters, perhaps on an assembly line of some sort. Life could be pretty miserable. Life might suddenly become much less miserable if I was moved to a different location that allowed more breathing room. I might report a definite improvement in my quality of life, decreased stress, and subsequent decrease in severity of tics simply because my boss took my condition into account.

We don’t know what else was going on in the life of the patient in this case report. We don’t know about changes in her life that might have decreased her anxiety about the condition. Perhaps simply receiving a hands on treatment from a perceived authority figure certain that they can provide help caused a decrease in anxiety that led to her improvement. We don’t know if her improvement was simply because of the natural course of her Tourette’s. All we know is that she reported an improvement after a year of chiropractic care. Correlation does not necessarily equal causation as the old saying goes.

Another aspect of placebo involves reporting bias. Patients who are emotionally invested in a therapy are more likely to report positively. Patients who like their physician or other practitioner, such as a chiropractor for instance, are more likely to report positively. Patients in a study, or who are going to be written about in a case report, are more likely to report positively in order to please the person in charge who stands to gain from positive results. There are other well established psychological entities, such as cognitive dissonance, that motivate positive reporting. Nobody wants to feel foolish, for instance, wasting a year of their life and the money required to do so on a failed therapy. None of these can be accounted for in case reports such as this.

But is this case report even useful as a hypothesis generator? Does it support the authors’ calls for more research into the chiropractic subluxation as the etiology of Tourette’s and chiropractic spinal manipulation as a treatment? Once again, the answer is no. While the exact cause of Tourette’s is not established, there is expert consensus that it has a genetic origin and is a disorder involving the connections between the cortex and subcortex leading to abnormal synaptic neurotransmission. Some experts have raised the possibility of an autoimmune etiology, particularly related to infection with Group A Strep, but this is controversial. There is absolutely no legitimate concern regarding the possibility that impairment of spinal nerves, as is claimed to occur in the presence of chiropractic subluxation, is a factor. Sure there have been instances where experts have been wrong, and as a skeptic I always leave room for surprising discoveries, but the evidence required to overturn the current consensus would need to be extraordinary. For the chiropractic community to raise this possibility based on an isolated case report this worthless is laughable.

Complementary and Alternative Medicine in Pediatrics in Review Part#1

As a pediatrician striving to continuously maintain a current fund of medical knowledge, and an educator of medical students and residents, I have been consistently pleased with the information provided by Pediatrics in Review (PIR). This American Academy of Pediatrics publication serves as a source for continuing education for thousands of pediatricians, and as a solid resource for doctors in training. Unfortunately, as I explained in my last post, over the past couple years there have been a number of articles published in PIR on the subject of complementary and alternative medicine which I feel have largely missed the point. They have simply not lived up to the standards that I have come to expect.

First and foremost, I believe that the authors of these articles likely have had good intentions but were ill-informed and were relying on information from questionable sources such as the website of the National Center for Complementary and Alternative Medicine (NCCAM). Also, probably in a noble effort to provide a fair assessment of the topic, several authors have committed errors of false balance and false compromise. These occur when the reader is given the impression that a particular alternative medicine entity has evidentiary support equivalent to more mainstream modalities or that a compromise between alt med and science-based medicine is the best approach to health care. Reality does not in general support either of these contentions. To be quite honest, however, I also suspect that there is more than a little investigative laziness at play, and personal bias in some cases.

A good example of the weak coverage of alt med in PIR is the recently published article on “The Ethics of Complementary and Alternative Medicine” by Brenda J. Mears. In Dr. Mears’ discussion of the ethics of alt med, which is far from the worst example of what PIR has published in this genre, I found several objectionable statements and a seemingly naive understanding of the subject matter. I was impressed though with her inclusion of a number of specific risks for direct harm from CAM therapies, such as vertebral artery injury from chiropractic manipulation of the neck, and for her call for pediatricians to be more aware of CAM. In general, we are fairly ignorant of what goes on in “the real world”.

A red flag that should raise suspicion that an author has a poor grasp of the history, as well as the current state, of alternative medicine in the United States is the quoting of the NCCAM definition of complementary and alternative medicine (CAM). The NCCAM’s defining of CAM in general as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” is about as helpful as defining the relationship between the three sides of any triangle as A squared plus B squared equals pineapple. In an equally useless fashion, and one which is also repeated nearly verbatim in Mears’ article, the NCCAM provides individual definitions for the trichotomous nature of what has come to be known as as just “CAM”. When used in place of conventional medicine, it is alternative. When used seperately but concurrently with conventional medicine, it is complementary. Finally, when alternative medicine is combined in a seemingly synergistic fashion with conventional therapy, it somehow magically transforms into integrative medicine.  It may be nice to have such easily digested categories, but they distract the uninitiated resident or pediatrician rather than help to provide any true understanding of the unrelated and often contradictory practices in question.  

Mears, once again borrowing information from NCCAM, expounds on the relationship between these categories and reveals, perhaps inadvertently, one of the key weaknesses with the concept. She writes, “The boundaries may blur, and some therapies once believed to be CAM, such as cognitive behavior therapy or prebiotic and probiotic use, now are considered by many to be conventional.” There is much wrong with this line of reasoning, and it illustrates perfectly why using CAM terminology is so problematic and uneccessary. The boundaries only blur because the boundaries the NCCAM use were manufactured to do just that, and in the process provide unearned respect for a host of unproven concepts and therapies. The true boundary, and it is a boundary between therapies not considered to be part of any CAM lexicon as well, is the one that seperates practices that work from those that do not, therapies that are safe from those that have not been proven to be so, and claims that have been subjected to scientific scrutiny from those that have thus far avoided it. This is all that matters.

CAM terminology promoted so heavily by the NCCAM and other proponents is about marketing, about obtaining awareness and acknowledgement without having to actually bring any evidence to the table other than anecdotes and testimonies. Thus, in reality, calling something alternative, complementary, integrative, or conventional for that matter, provides no real and useful information. Each of those categories contain within them treatments that have failed the test of science. And each of them contain treatments that have the potential to provide objective benefit in the treatment of human disease. The use of CAM terminology has led to the existence of a double standard where individual therapies, given the right label, are not judged on plausibility and scientific evidence. Instead they receive a free pass that allows the circumventing of a process that has led to advancements which have greatly decreased suffering in the world and added decades to our lifespan. And with the current “cerebrum excedere” approach to health claims taken in both public and academic circles, this is all that it has taken for large percentages of the population to be taken in by outright quackery.

But why would being lumped together with other unproven therapies provide unearned credibility? The reason this occurs is because, as Mears reveals in the above quote, proponents of individual therapies use the fact that some therapies considered to be CAM are accepted as part of science-based medicine. This tactic is especially easy to employ when the “therapies once believed to be CAM” that are now “considered by many to be conventional” are things like nutrition, exercise, smoking cessation, and various plant based pharmaceuticals. By essentially co-opting/stealing avenues of research and proven preventative measures that are science-based, a large foot has been shoved in the door for all manners of pseudoscience to slip in. Just because plants are investigated by scientists for their potential role in improving the human condition, and those investigations have led to a number of safe and effective pharmaceutical interventions, it doesn’t mean that the unregulated use of unproven herbs, or that healing touch for instance, is legitimate.

Mears claims that conventional medicine is “intended to be based on knowledge of safety and efficacy obtained from randomized, controlled trials (RCT) and attempts to avoid treatments that are not supported by such evidence”. This is an straw man definition of what we do and allows proponents of pseudoscience and quackery to simply chalk the objections of scientists and skeptical doctors such as myself up to some kind of religious devotion to the RCT. RCTs are the gold standard when it comes to determining whether or not a treatment actually works, but the practice of science-based medicine takes into account all evidence, from clinical observations and anecdotes up to the RCT, including our understanding of basic science and the overall plausibility of a claim. Does Dr. Mears think that we only hang our hats on RCTs to support telling a patient to stop smoking because it increases the incidence of lung cancer, as if there was an IRB approved prospective trial where we encouraged subjects to smoke so that we could compare lung cancer rates to a group smoking sham cigarretes. Much of the evidence we use to support treatments and lifestyle recommendations does not come from an RCT. 

She then admits, in what may be the understatement of the year thus far, that “CAM therapies may have fewer supporting data.” May have fewer supporting data? Is that even up for debate? I guess it is depending on who you ask. If a treatment that is considered to be CAM, and I mean real CAM not a co-opted science-based therapy, had decent evidence to support its use it wouldn’t be CAM. The most functional definition of CAM is stuff that doesn’t have any supporting data to speak of and likely will never have any supporting data, or stuff where a definitive answer has been arrived at but ignored. Think homeopathy or anything a chiropractor does that a physical therapists won’t. Think manipulating human energy fields or the use of herbs and supplements like echinacea for the cold or ginkgo biloba for memory problems. Of course CAM therapies have fewer supporting data. That flaming ball of fire in the sky is also actually a star, and it’ll come back in the morning. I promise.  

She follows this shocking revelation with the obvious statement that there are mainstream practices as well as  CAM “activities” that lack “rigorous evaluations.” She explains how this does not exempt any of us from backing up our practices with the latest and greatest scientific evidence, something which she claims the NCCAM is doing. Well, not exactly. There may be a some well-designed studies coming out of NCCAM but, as the past decade has shown us, their negative results have little to no impact on the belief of CAM practitioners and could have come from other areas of the NIH that don’t have so much baggage and bias. The NCCAM spends roughly 128 million dollars per year, and has spent over a billion dollars in total, producing a few good negative studies and numerous poorly designed positive studies that somehow all lead to the conclusion that more studies are needed. Furthermore, in its efforts to serve its master, Senator Tom Harkin, as a propaganda machine for unproven therapies, the bogus marketing terms “complementary” and “alternative” are now so firmly attached to the word medicine I am forced to use them liberally in any attempt to discuss this application of magical thinking to my chosen profession.

I’ve got a few more bones to pick with this article, but I’ll save them for my next post.

Alternative Medicine and the Vulnerable Child…..

A concept that has been well-recognized in pediatric medicine, at least since it was first described in 1964, is that of vulnerable child syndrome (VCS). In the past, I have mistakenly refered to this entity as “sick child syndrome” but that is problematic in that it implies that it only occurs in the aftermath of illness. As I will explain in detail, there is much more to the development of VCS and it is the concern of VCS in children without true medical problems that led me to the connection with alternative medicine. I’ll explain, but first a primer on VCS.

VCS is a potential consequence of extreme parental anxiety in response to the perception of vulnerability in their child. This perception leads to abnormal parental behaviors, such as overprotection and excessive focus on future health complaints from that child. Ultimately, these behaviors can result in the child suffering severe separation anxiety, behavior problems, difficulty in school, and abnormal fixation on their own health. It is also very common for families with VCS to overuse medical services, sometimes seeking medical attention in emergency departments or physician’s offices several times each month, and there have even been links to physically abusive relationships between children and their families. 

The parental anxiety at the heart of VCS tends to be initiated by the diagnosis of significant illness in a particular child, or by a high-risk pregnancy/delivery during which the life of the child or mother was at risk. But, and this is important, it can occur even when the illness in question is not serious, or when there isn’t any illness in the first place. It is, after all, the perception of vulnerability that is at the heart of VCS. This unfounded anxiety can even stem from something as seemingly innocuous as a false positive newborn screen result that is quickly determined to be spurious.  Naturally, as with most disorders of a psychological nature, factors that can potentiate the untoward effects of VCS can include environmental and family stress, poor social support and low socioeconomic status.

 I often discuss the role of pediatric medical professionals in the development of VCS with colleagues but I am frequently disappointed with these interactions and left feeling as if it is an issue that doesn’t receive the respect that it deserves. I think that for many providers, the fear of missing a potentially serious medical condition, even a very unlikely one, outweighs the risk of longterm psychological complications that can sometimes occur when we dust off the old diagnostic shotgun or go on investigatory expeditions with low pre-test probability of success.

There is also, I think, a general acceptance of performing tests to “rule-out” problems rather than to “rule-in” problems that are felt to be likely based on history and examination. This is common amongst medical practitioners as well as lay persons. Recently a friend asked me what harm lay in obtaining medical tests that may not actually be necessary but might serve as a means of comforting a family, or a physician, that is worried about a particular disease process. The answer, of course, is that our tests often are imperfect and have a large subjective component to their interpretation which leads to a large number of false positive determinations. These false positives lead to more intervention, much of which has inherent risk associated with it, and they can lead to VCS in some instances. There are other reasons to avoid unnecessary testing but to me this is the most important.

A common example of this occurs when the prototypical febrile 15-month old with symptoms consistent with a viral lung infection is brought into the emergency department or primary care doctor’s office during the Winter months. The evidence is clear that these kids, with rare exception, do not have bacterial pneumonia and do not benefit from the routine ordering of chest films or complete blood counts but they are very frequently obtained anyway in order to rule out something which would require antibiotic therapy. These xrays and labs are often equivocal or consistent with a viral lower respiratory process, but studies in these situations tend to serve as a Rorschach inkblot test with the interpreter seeing in them whatever he had already decided was causing the symptoms. In these cases, it is a bacterial process and the IV antibiotics are soon running.

It is a very difficult task for a hospitalist to explain why an intervention that was just begun is being discontinued, especially one which makes such intuitive sense to a family. The physician ordering the antibiotics typically does not explain the ambiguities of such a diagnosis. They do not typically explain the extremely low incidence of bacterial pneumonia in such situations, or even discuss the difference between viral and bacterial pneumonia. They tend to walk in and confidently diagnose a bacterial pneumonia, and the use of antibiotics for pneumonia is seemingly hardwired in the psyche of the general public. So when I stop the ceftriaxone, and begin talking about viruses and the reassuring chest xray obtained the night before, I sometimes meet up with parental anxiety and resistance to supportive, non-pharmaceutical interventions. On many occassions, I’ve seen these families during future admissions where a history of bacterial pneumonia is given. Sadly, I also have experienced on many occassions the subsequent concerning changes in how these children are cared for, such as the concern for another episode of bacterial pneumonia leading to seeking emergency care in the middle of the night for what is clearly another viral infection that could have been treated at home, or could have been easily handled by their primary care physician the following morning.

So what is the connection between alternative medicine and VCS? It is actually pretty obvious and I’m feeling rather sheepish about not having thought of this before. The science-based practice of pediatric medicine and the confusing jumble of unproven modalities lumped under the term alternative medicine differs in many ways. One of the most prominent is the plain fact that when a child is brought to a practitioner of (insert random alt med entity), or that child’s parents visit the website of a proponent of such an entity, they are rarely if ever told that nothing is wrong. There is always something that can be fixed, often with multiple visits or supplements which just so happen to be sold right there in the office or by the author of the website. Chiropractors tend to find subluxations. Practitioners of traditional Chinese medicine discover stagnant chi. Naturopaths uncover ill effects of a toxic world. Numerous quacks order blood tests designed to confirm their suspicions of harmful heavy metal levels. Countless websites tout hypothyroidism and adrenal fatigue as near ubiquitous etiologies for any symptom you can dream up. Or maybe it is all because of abnormal body acidity. Or yeast. Or liver flukes. All of these have been proposed as the cause for almost all illness. 

In contrast, as a pediatric hospitalist, someone who by definition only takes care of children sick enough to be admitted to a hospital, I still spend a large percentage of my day reassuring parents and patients that things are going to be okay, that their child’s condition is self-limited and that they will return to full health. On many occasions I prescribe no treatment at all, and participate in what has been called “masterly inactivity”, the calculated observation of a child in order to avoid unnecessary testing or pharmaceutical intervention. In the day to day workings of a primary care doctor, the overwhelming majority of visits are for well children check-ups or self-limited complaints with most receiving only advice and reassurance. We are able to this because most of us strive to base management decisions on the best evidence available, as free as is humanly possible from biased interpretations and certainly free from the impact of an irrational devotion to any unscientific and unproven belief systems. There are exceptions of course, but these are not common.

I am forced to recognize that despite my best efforts to reassure some families, there will be times when a pathologic anxiety will develop. To give just one example, it seems painfully obvious that if the family of a healthy child brings their child to a chiropractor, and were told that one or more subluxations exist which need immediate treatment, and longterm maintenance treatment to prevent their recurrence, that the risk of VCS would be very real. Just google the terms “SIDS” and “subluxation”, and you will find chiropractic websites and articles discussing that connection. Now imagine the fear that some families must go through believing that their child is at risk of dying in their sleep if they don’t see a chiropractor, as is recommended by many of them, in the newborn period. This is just one of innumerable examples of alt med practitioners sowing the seeds of fear and anxiety by validating fictional problems. There are worse, much worse.

What really got me thinking about VCS in this context was the recent publication of an article on the ethics of complementary and alternative medicine in Pediatrics in Review. Peds in Review is the journal of the American Academy of Pediatrics (AAP) and is geared towards continuing education for pediatricians. It contains review articles, quizzes, and cases designed for maximized learning, and is heavily used by pediatric residents. I’ve been reading it monthly since 2003 and have noticed the steady creep of alternative medicine nonsense into its pages, usually with review articles of the use of alt med for specific medical diagnoses. These articles tend to be poorly written and seem to rely on misinformed or biased sources such as the National Center for Complementary and Alternative Medicine (NCCAM), a propaganda machine for alt med that has also wasted over a billion taxpayer dollars on studying alternative practices with zero plausibility and heaps of prior negative studies. Much of their budget goes towards supporting biased unscientific alt med education in medical schools, hence my use of the word propaganda.

Although this particular article was perhaps a little better than many treatments of alternative medicine by the AAP, it still left a lot to be desired. My next post will focus on the errors in the article. At no point in the discussion did the risk of VCS come up. I believe that although there are greater potential risks of exposing children to these unproven modalities, the development of VCS should certainly be included. I would not be surprised at all if VCS is a much more common outcome than those other more serious bad outcomes like stroke from manipulation of the neck or toxicity from unregulated herbal supplements.

Top Ten Phrases That My Residents Will Be Tired of Hearing After Three Years…..

1. The three most dangerous words in medicine are “In my experience…..”

2. Don’t poke the skunk!

3. Don’t just do something, stand there!

4. Bad things get worse, not bad things get better or stay the same.

5. The plural of anecdote is anecdotes, not data.

6. The most successful interactions with patients and other medical professionals occur when they think it was their idea to do what you wanted them to do all along.

7. Sometimes kids forget to read the textbook chapter that discusses their diagnosis.

8.  Never underestimate the ability of the human brain to fool itself, especially your own.

9. You can swing a dead cat over the kids bed and he’ll get better as long as you do it for (insert time frame for typical resolution of self-limited illness).

10. Don’t believe anything a patient or family tells you about what another medical professional said to them.

Bonus (No longer said since I don’t take care of newborns anymore): It’s generally poor form to send a kid home without an anus.

Pediatric Residency Day One…..

On July 1st, I found myself in a very unique position. I arrived for work at 7 AM and found waiting for me two eager but nervous new residents ready to work, and more importantly to learn. And six other interns were scurrying around somewhere else in the facility or at their continuity clinic across town. This was day number one of a brand new pediatric residency program and it is a big deal. New programs, especially in pediatrics, are rare occurrences and I am lucky to have practically stumbled into being a part of this one.

I’ve worked with hundreds of residents at other institutions in the past but this is different. My role in this program is much more significant in that the majority of their time spent learning how to take care of hospitalized pediatric patients will be with me. In addition to their time on the inpatient units, I will also be giving numerous resident lectures throughout the year on topics of my own choosing. These eight young doctors, and the many future classes yet to come if things go according to plan, will be heavily influenced by what I have to teach them.

I would be lying if I said that the thought of eight new residents per year looking to me for guidance isn’t satisfying to my ego. It would be for anyone. But I’ve spent a lot of time thinking about this and have come to the realization that this opportunity is not about personal satisfaction. I am taking this more seriously than anything I’ve ever done in my career thus far.

Every day I look around me and am mystified at how little critical thinking plays a role in our lives. I’ve said it before, and I’ll say it again now, it is as if we live in a society that has allowed reason to take a backseat to emotion and critical thinking to be subservient to magical thinking. It is painfully clear to me that in this country science is still looked upon by many with fascination, which is good, but also by a growing number of people with disdain. Some even actively oppose it. And even many of those who do recognize the power of the scientific process to unravel the mysteries of the natural world seem to believe that scientific thinking and skepticism are activities for scientists and geeks like me rather than as a useful skill that can be acquired and put to good use by everyone.

In the world of medicine, where I spend the majority of my time, I see this frequently despite the fact that this world is populated by men and women who have devoted their lives to translating scientific progress into bettering the lives of others. I see this despite the fact that many who also exist in this world have educational backgrounds heavily influenced by science. As medical professionals, most of us are not scientists but, as stated above, are responsible for taking science and making it work in the real world. Unfortunately, that doesn’t always equate to a medical professional thinking scientifically or acting rationally when caring for patients. Not that being an actual scientist is a foolproof means of avoiding the path to irrational thinking. That path is well worn and a much easier route to take for anyone regardless of whether or not they have a PhD. History is full of examples of brilliant scientists checking their reason at the door.

I am taking my role as primary educator for these new interns seriously, not because it is a leap forward in my career, but because it is a privilege. These young doctors deserve to have their education taken seriously, and more importantly, so do their future patients. And one day, each of these interns will have opportunities to educate others. This includes future generations of residents, other medical professionals such as nurses, patients, parents, and the public. The medical knowledge I share with them, or more importantly the skeptical mindset that I will attempt to instill in them, might over time be carried over to thousands of others, like a reverse pyramid scheme where information goes down instead of money going up. It is exhilarating while at the same time it is quite humbling.

One of my favorite expressions, and one which I wish I could claim credit for, is that the three most dangerous words in medicine are “In my experience”. When we begin to rely too heavily on our own experience, we are perhaps too far along the path of unreason to ever find our way back. Using experience to guide medical practice is risky because the devices that have been installed, maintained, and periodically updated by evolution to interpret reality, as amazing as our human brains can be, are flawed. Experience, although a useful if not clumsy means of discovering where to focus the much more powerful lens of science, steers us in the wrong direction much more often than it leads to advancements in our understanding. I owe these residents better than my personal experience.

During rounds on day one, after introducing the new interns to the nursing staff and highlighting the concept of the team as an approach to medical care, I went over a few ground rules and personal promises (admittedly a little better fleshed out here):

  1. You will never be told to do something because I said so or because that is the way I do things. I expect you to support your management decisions as you should expect me to support mine, not with experience but with evidence. If no evidence is available, we will support our decisions with plausibility at the very least. This is the very essence of science-based medicine.
  2. Expect to be questioned, and prepare for it. I expect to be questioned by you. The only bad question is the one you don’t ask. Do not be afraid to be wrong or to reveal that you need help. Do not be afraid to ask for an explanation because you didn’t get it the first time. This is not the playground in 3rd grade and you will not be made to feel stupid or embarrassed for making a mistake or not grasping a complicated concept the first time it comes up. Expect to be questioned by patients and their familes. In fact, encourage it.
  3. There will be times when we come to two different conclusions regarding a patient’s care. I do not outrank you. My experience, although it may lead me to think differently about a particular situation or lead me down a different diagnostic path, ultimately should not play a role in whether or not my decision constitutes the best approach to a patient’s care. If you can back it up better than I can, we go with your plan.
  4. The approach that makes the fewest assumptions is likely the best approach. For example, if you admit a 2-year-old with multiple fractures and bruises, don’t assume that someone else thought about or ruled out child abuse. If you admit a 5-month-old with fever and dirty urine, don’t assume that someone else sent a urine culture. Don’t assume that the dose for antibiotics ordered by another doctor, even me, especially me is correct. Do assume that you are the only person responsible for caring for each patient and act accordingly. (Sort of a modified Occam’s Razor)
  5. Don’t poke any skunks. Ordering labs or imaging that you don’t really need will rarely result in a positive outcome and has potential for many negative consequences.
  6. Always strive to be aware of your own limitations, in both medical knowledge and in thinking. We are all biased in many ways, often without realizing it, and this can affect our medical practice. For example, when you admitted that 15-year-old with fever and sore throat, why did you look up diagnostic criteria for Lemierre’s Disease and order a CT scan of his neck when his presentation is much more likely to be a result of infectious mononucleosis or strep throat? Was it because you had a patient last week with Lemierre’s who you had to transfer to the PICU or because it truly deserved a high spot in the differential? The hoof beats of zebras sound exactly like those of horses, but which do you really expect to come see galloping around the corner.
  7. Things are not crazier during a full moon! And I’ve got the evidence to prove it.
  8. Wikipedia and Google are good places to start but would you tell the parent of an ill child that Wikipedia recommends an infusion of IVIG?
  9. If you are only going to remember one thing, remember to respect the nurses and to learn from them. And remember to share your rapidly expanding fund of knowledge with them in a respectful and constructive way.
  10. When in doubt, about anything, call your attending. Do not worry about bothering or annoying us. Worry about taking care of the patients in the best way possible because that is your ultimate responsibility.

My goal, lofty as it may be, is that every resident  graduating from this program will be armed with the skills to practice medicine safely, effectively, and skeptically. With the ubiquitous nature of the internet, the near entirety of medical knowledge is at almost everyone’s fingertips. To be a good doctor, it is becoming less important that our brains are stuffed with medical knowledge because of that ease of accessing information. But what is becoming increasingly vital as our rapidly progressing understanding results in staggering complexity, is the ability to unravel that complexity and provide care based on solid evidence while avoiding the numerous errors in thinking and emotion based biases that we are so prone to. Nobody is perfect, certainly not me, but I promise to do my best to assist these new physicians in fulfilling their potential.

The Truth Behind Herbs and Supplements…..

For a few years during my high school and college days, I was into supplements. I was also into country music, but nobody is perfect. I took vitamin C to ward off colds, B vitamins for increased energy and ephedrine for weight loss to name just a few. My excuse? Like the ancient Chinese who supposedly used acupuncture 5,000 years ago*, or the 18th century American physicians who bled their patients to remove excess bodily humors, I was prescientific.

In contrast to those dark days, as a result of my discovery of the work of James Randi and the modern skeptical movement I spent the early years of my pediatric residency developing an interest in so-called alternative medicine. My eyes were opened as I learned about the reality behind the substances I ingested with the fearlessness of ignorance and I became embarrassingly aware of the simple fact that science just doesn’t support the near entirety of claims made by the manufacturers of herbs and supplements**. Despite this, these products can be found on the shelves of thousands of stores across this country and they rake in billions of dollars annually. Unfortunately, consumers are generally unaware of the science, or rather the lack of it, behind these products, and of the risk that they take each time they head down to the GNC or Rite-Aid. 

If I were to walk out my back door and take a random sampling of the available plant life, place those clippings of various flowers, weeds and grasses in my blender, and press liquefy, the end result would have the potential to make me a very rich man. To the untrained eye it would appear to be merely a glass full of grass juice, and to the naive mind a nasty and useless concoction. But to an individual initiated in the unethical reality of herbs and supplements, it might just be a gold mine. You see, all it would take to turn green grass into green cash is the current state of regulation of herbs and supplements in the United States and a vague structure/function claim. 

Here’s how it works. Since the early 90’s, 1994 to be exact, with the passage of the Dietary Supplement Health and Education Act, the supplement industry has essentially existed as if stuck in the days of the American Old West. The Law of the day, much like our current Food and Drug Administration, served as a means of maintaining a somewhat controlled chaos. Try this excerpt on for size, podnuh. 

“Under the Dietary Supplement Health and Education Act of 1994 (DSHEA), the dietary supplement manufacturer is responsible for ensuring that a dietary supplement is safe before it is marketed. FDA is responsible for taking action against any unsafe dietary supplement product after it reaches the market. Generally, manufacturers do not need to register their products with FDA nor get FDA approval before producing or selling dietary supplements.” 

Now just let that sink in for a moment. Wait for it. Wait for it. Has it hit yet? Has that feeling of emptiness and despair that I experience on a near daily basis during my frequent adventures in the Land O’Woo settled in yet? Allow me to break this down for you. Since 1994, when the FDA was sent outside to fetch its own switch so that Congress could more effectively tan its hide, manufacturers have had no oversight whatsoever when it comes to determining whether or not their herb or supplement is safe. My fictional grass juice, which I’ll have you know has been used by Native Americans to cure teeth itch and hair pain for thousands of years, could contain iocane powder*** and kill several consumers before the FDA would be able shut down my operation. In fact, as I am writing this there are herbs and supplements sitting on store shelves which contain toxic levels of heavy metals such as lead or mercury and which are adulterated with pharmaceuticals****. When enough people are harmed by an herb or supplement, such as in the infamous case of ephedrine a few years ago, the FDA investigates and the product is pulled. There are thousands of new supplements that go on the market each year and the emergence of the next Ephedra is only a matter of time. 

But what about effectiveness? Unfortunately, DSHEA rains on that parade as well. There is no requirement under the law for an herb or supplement to be proven effective by the company selling it as long as the claims made fit certain criteria. If claims of positive impact on a specific disease are made, then the FDA has the power to make sure that the evidence supports those claims. If vague claims involving support of structures or bodily functions are made, then the FDA is impotent. So if I attempted to market my backyard grass juice to cure epilepsy, I wouldn’t get very far. But if my infomercial talks about supporting brain health (wink wink, nudge nudge) or improving neurological function, I’ll be opening my Swiss bank account in no time. 

The dangers of DSHEA and the herb and supplement racket actually go much deeper than this brief discussion goes into. I’ll devote additional posts to these issues but I encourage my readers to take the next step and investigate for themselves. A great place to start, as it is with any healthfraud or alternative medicine related topic, is Science-Based Medicine

*The Chinese weren’t using acupuncture 5,000 years ago despite what numerous news reports and press releases claim. What is known today as acupuncture has only existed for the past several decades and has failed the test of science. 

**These manufacturers are typically subsidiaries of the mammoth pharmaceutical companies so reviled by the alt med crowd. Awareness of this fact has forced many a believer to erect additional impenetrable walls of cerebral compartmentalization to avoid the coma inducing cognitive dissonance. 

***Iocane powder is a deadly poison that is odorless, tasteless and highly soluble. It is only available in powder form and was once popular for use during battles of wits when death was on the line, particularly with Sicilians. Although it takes a few years, determined individuals are capable of developing immunity to the poison. 

****Actual Viagra has been found in supplements bearing claims of male enhancement!

Fever Phobia #2: The High or Unresponsive Fever…..

**Disclaimer** The following discussion is, in my opinion, good medical advice for most caregivers but it does not constitute specific medical advice for you or your child. There do exist specific situations where children with fever are treated differently because of age or underlying medical conditions. For instance, neonates and children with sickle cell disease are treated very differently than a healthy nine-year-old with even a fever of 106 degrees. I strongly recommend that anyone reading this or any other post regarding medical topics discuss any medical concerns with their child’s primary care physician. **Disclaimer**

Fever phobia is everywhere. In preparation for writing this post I took just a few minutes to peruse the internet and, not surprisingly, found a seemingly never-ending supply of flawed information. A great deal of this misinformation can be found in places where I would expect it, such as on chiropractic websites and parenting message boards. But much of it is put out by what would seem to most people to be legitimate sources, including the websites of pediatric practices.

A number of studies looking into fever phobia have consistently found that two of the most common concerns expressed by parents and medical professionals are the risk of health problems related to highly elevated temperatures and to fever that does not respond to antipyretic medication such as acetaminophen and ibuprofen. This concern seems to be based on a number of misconceptions, in particular the unfounded belief that the height of a fever positively correlates with the severity of the infection and that fever over 104-105 degrees can cause brain damage, seizures, hearing loss, or even death. As I will shortly explain, both of these concerns are unwarranted.

Fever due to infection, rather than hyperthermia due to being left in a hot car on a Louisiana Summer day, is a homeostatic process. When the body is exposed to infectious organisms such as viruses and bacteria, a number of so-called pyrogens are produced as part of the inflammatory response. These pyrogens can then act to raise the core body temperature set point, which is regulated in the brain by the hypothalamus. The body then undergoes a variety of physiological and behavioral changes in order to increase our core body temperature to match this new set point.  These changes include the clamping down of blood vessels in the skin in order to decrease heat loss, shivering to produce heat, and raising the ambient temperature with blankets and heaters.

At a certain core temperature, depending on the age of the person, the type of infection, the intake of antipyretic medications and certainly a number of currently unknown feedback mechanisms, the body will put into play measures to lower the temperature set point. Our peripheral blood vessels dilate, we become flushed and break into a sweat, and we crank up the AC. This will occur 100% of the time, even if no medications are given to assist the process. It is physiologically impossible, in the setting of infection alone, for our core body temperature to be raised higher than 106-107 degrees without inappropriate exposure to an external heat source.

Even at that extreme of possible core body temperature mentioned above, there is no direct link between fever and brain damage, hearing loss, or death. The height of fever is an independent risk factor for febrile seizures, but treatment does not prevent their occurrence. I covered febrile seizures in an earlier post. There is an indirect association, and this is likely why the fear emerged initially, between fever and poor neurological outcomes however. An infection, in particular a severe bacterial infection involving the blood and/or brain, which has led to a febrile response may, unfortunately, ultimately lead to these dreaded complications. But it is the underlying infection to blame, not the fever. Treating fever in these instances does not improve the outcome.

In addition, the height of fever has not been reliably linked to the severity of the infection that has caused it, especially in the post-vaccine era. A patient can have a life-threatening case of Haemophilus or Staphylococcal meningitis with no appreciable fever just as a child with a minor viral upper respiratory infection can spike to 105. Many protocols in use today still base treatment decisions on the height of fever, but they are not based on current evidence and they lead to increased practitioner/parental anxiety and overuse of testing and imaging modalities. Similarly, a fever that does not come down after administration of an antipyretic is not more likely to be caused by a severe infection. It just doesn’t work that way. What is more important is how the child looks, regardless of what their temperature does with Tylenol on board. A lethargic toddler with a stiff neck, or an infant that refuses to feed, needs to be evaluated while a playful 4 year-old with draining snot and a temperature of 103 degrees can probably just be watched in most cases.

At the heart of fever phobias such as these, is the general misunderstanding of fever as a disease in and of itself. It is more helpful to think of fever as a symptom in the same way we might regard heartburn. There is something that leads to the development of fever, typically an infection, and it is likely that there is a good reason for the febrile response to be so prevalent in the animal world. Although it hasn’t been replicated in humans, studies have shown decreased mortality in a variety of other species related to mounting a fever in response to an infection. There are hypotheses as to why fever may be beneficial. Perhaps pathogens are unable to replicate as efficiently, or perhaps our immune system is more effective, when core body temperatures are elevated. It is a fascinating area of study.

Thinking of fever as a symptom rather than as a disease helps to put it into perspective. Many people, when their head begins to ache after a long day at work, reach for an analgesic medication such as Ibuprofen or Naproxen while others prefer to see if it will progress before attacking that childproof lid. Some will even tough it out until the pain is excruciating or forego treatment alltogether. Almost all headaches will eventually resolve on their own. The overwhelming majority of headache sufferers do not treat their headache because they are worried that the headache itself will lead to a bad outcome, such as a brain tumor or stroke. They treat the headache because it makes them uncomfortable and they will only seek medical attention in certain instances. With fever, parents absolutely should treat with antipyretics when their child is uncomfortable. Helping a sick kid feel better, in my opinion, is more important than preserving the possible minor benefit gained from a febrile response to infection. And parents absolutely should seek medical attention when the fever occurs in the context of other risk factors for serious infection, such as age less than 28 days or a very ill appearance, to single out just a couple. When in doubt, I always recommend that a caregiver call their child’s pediatrician or family doctor. In general though, if you have a healthy older child who doesn’t seem to be bothered by the fever it is okay to not give antipyretics, and it is okay to not even recheck the temperature. Just focus on their appearance and behavior.

A 2001 study in Pediatrics revealed that almost 75% of parents sponge their children in the setting of fever, with many doing so at temperatures of less than 100 degrees. This is problematic for two reasons, the most important of which is that sponging doesn’t work. And if you are one of the two-thirds of parents that use improper technique, then you may be making your child more uncomfortable and putting their health at risk. The proper technique, or at least the technique least likely to add insult to injury, is the use of a sponge or rag soaked in tepid water to dampen a febrile child’s head and neck. While this might lead to some subjective improvement, perhaps secondary more to the loving attention of the child’s caregiver than to any specific effect, it will not lower core body temperature. Unfortunately many caregivers use cool or cold water to sponge with, submersion in cool or cold water, application of ice packs and even topical rubbing alcohol in an attempt to treat fever. These techniques are ineffective and potentially dangerous in the case of rubbing alcohol. Use of cool or cold water leads to constriction of skin blood vessels and impairs the child’s ability to lose heat which can cause intense shivering. This is uncomfortable and actually raises body temperature. Rubbing alcohol can be absorbed through the skin and result in lethal toxicity.

Some have described fever as our friend, typically as a means of getting across the message that it might actually have a beneficial purpose during an infection. Some friend. Fever can make a child feel absolutely lousy and I don’t blame parents for not wanting it to come over and play after school. Although the evidence is not clear that fever plays a significant positive role during some illnesses rather than the traditional part of the Snidely Whiplash, it is clear that fever phobia is counterproductive and potentially harmful. The same studies that delved into parental and medical professionals’ fears regarding fever also showed us that concerning numbers of parents give doses of antipyretics that are higher and more frequent than recommended. They also showed that a majority of parents will give, and medical professionals will recommend, alternating Tylenol and Motrin despite the lack of evidence for safety and efficacy of the practice. The AAP specifically recommends against it.

The final fever myth I’ll discuss is the belief that medications, like Tylenol and Motrin, are safe because they are over-the-counter. The truth is that they are both pretty darn safe, especially acetaminophen, but there are reasons to be cautious. First and foremost, if there is no benefit from the administration of a medication, any risk is unacceptable. Giving antipyretics to comfortable children with fever falls into that category most of the time. Tylenol, when overdosed, can cause irreparable liver damage. Motrin, even when dosed appropriately, can cause kidney and gastrointestinal damage, especially in the context of dehydration and it should not be given to children under 6-months. During the first several years of life for most children, there will occur numerous febrile episodes. During many if not most of them, there will be a legitimate need for antipyretic medication. But it is impossible to make rational decisions regarding the care of a child without the proper information to base those decisions on. Acting out of fear, and on misinformation, should be avoided at all costs.

Foundations of Skepticism: Confirmation Bias…..

In a prior post, I described one of the most vital supporting pillars of skepticism: the requirement for increasingly powerful evidence in support of claims that push the limits of plausibility and call into question fundamental aspects of our scientific knowledge. In this post, I’m going to reveal an inherent flaw in our ability to accurately interpret causal relationships in the natural world. This flaw, known as confirmation bias, serves as the driving force behind almost all unfounded belief systems and the primary reason why anecdotes and testimonials are unreliable.

Examples of confirmation bias are all around us. Nobody is completely immune to its sirens’ call, and partial immunity can only occur with awareness of the concept and a constant struggle to avoid its influence. The feeling one experiences when realizing that they are wrong, especially regarding something that they are emotionally invested in, is unpleasant to say the least. Our brains, and thus our minds, have evolved to avoid this feeling even if we must sacrifice an accurate assessment of reality. We do this via three different mechanisms, all of which revolve around our tendency towards biased selection of information that supports what we already believe to be true.

1. The selective collection only of information that confirms (biased collection)
2. The selective interpretation of information in such a way that confirms (biased interpretation)
3. The selective recollection of only information that confirms (biased recall)

The net effect of these mental mechanisms is the overemphasizing of only some of the available data or information regarding a claim. The best example that comes to mind, and one which melds this topic with the practice of medicine, is that of the commonly held belief in so-called lunar effects. This is the hypothesis that the full moon has effects on the human body. These include effects such as increased rates of mental illness and suicide, and spikes in birthrates. High percentages of medical and law enforcement professionals accept lunar effects as a true phenomenon despite the fact that they are highly implausible and have been thoroughly disproven by the collective data of over 100 studies. So why does this pervasive belief persist?

The answer is confirmation bias.

When a strange event occurs, or there is an odd cluster of events, during a full moon, such as the unlikely need for the delivery of a baby in a pediatric emergency department, many will  assign a causal relationship (biased interpretation) because they already believe in lunar effects. Others may make the connection for the first time because of prior exposure to legendary effects of the moon as with werewolves or its association with witchcraft, or because, after the fact, they hear of the many unusual things that have happened during a full moon from coworkers (biased collection). They may link the full moon to the strange event simply because humans are uncomfortable with the random nature of the natural world and a full moon is sexy. As storytelling primates, we often force explanations where none exist, and we love a good tale. This is what humans have evolved to do, and we do it better than any other species. At times, we do it too well. When a strange event or cluster of events occurs when the moon isn’t full, no connection is made. We do not interpret this as evidence against the previously assigned causal relationship (more biased interpretation).

Over the years, as the number of shifts in the ED pile up and random weird events continue to occur both during and not during the presence of a full moon, we tend to only remember the former (selective recall). Also, because human memory is malleable and changes with time and multiple retellings as in a childhood game of Telephone, strange events that did not occur during a full moon can drift to fit our beliefs. The occurrence of an ED delivery two weeks before and five days after a full moon two years ago may morph into that night we had two babies born during a full moon. The memory, although as false as a blatant lie, is no less real to the individual recalling it.

All of this is reinforced by the popularity of the belief, and to a lesser degree by misconceptions regarding the actual effects of the moon on the earth. Think tidal forces. Yes, it is true that the human body is largely made of water but in reality I am exerting more of a tidal force, or gravitational pull, on my keyboard as I type this than the moon does from 239,000 miles away. In fact, there is more gravitational pull on the earth during a new moon than a full one because a new moon lines up with the sun. But because of the dramatic visual stimuli that a full moon provides, this post isn’t about new moon madness.

So what are we do to about confirmation bias? Is it really an unavoidable pitfall? Well, perhaps not entirely unavoidable but it is an obstacle that has felled even the most powerful of minds. The best defensive strategy against this hardwired mental defect is an understanding of the fallability of human perception. The best offensive measure is  active exposure to information that does not fit within the cozy confines of our personal worldview. And giving scientific discovery more weight than personal anecdotes wouldn’t hurt either.

Fever Phobia #1: Febrile Seizures…..

I’ve been asked to speak at a upcoming city-wide nursing conference, and it took all of about three seconds to think of a topic: fever. Across the board, and that includes physicians as well as nurses and parents, an understanding of the pathophysiology of fever due to infection is lacking, and the approach to its treatment is problematic. The number of blatant misconceptions regarding childhood fever truly is staggering. Since the early 1980’s, when the seminal paper on the subject of fever phobia was published in the Journal of the American Medical Association, there have been several additional studies confirming and cataloging the causative factors and potentially dangerous resulting behaviors.

Fever is one of the most common reasons for parents to seek medical care for their children as well as a frequent impetus for late night phone calls to sleepy hospitalists. Elevated body temperature also serves as a source of unnecessary laboratory tests and imaging time and time again, which further reinforces parental fever phobia. These tests, along with the inappropriate monitoring and treatment of fever, lead to significant amounts of discomfort for children and even puts their health at risk.

My goal for the next few posts is to discuss a number of the most commonly held myths regarding childhood fever and to provide some evidence-based recommendations on what to do when the mercury, as well as the anxiety level, is rising.

**Disclaimer** The following discussion is, in my opinion, good medical advice for most caregivers but it does not constitute specific medical advice for you or your child. There do exist specific situations where children with fever are treated differently because of age or underlying medical conditions. For instance, neonates and children with sickle cell disease are treated very differently than a healthy nine-year-old with even a fever of 106 degrees. I strongly recommend that anyone reading this or any other post regarding medical topics discuss any medical concerns with their child’s primary care physician. **Disclaimer**

First up, febrile seizures.

One of the most common reasons stated by parents, as well as medical professionals, for their concern regarding the onset of fever in a child is the specter of febrile seizures. While it is true that there is an association, and likely a causal one, between fever and seizure activity in some children, the terror I often see in the eyes of caregivers is very often unwarranted albeit understandable, as is the use of antipyretic medications like acetaminophen ibuprofen (Tylenol and Motrin for most readers). Confused? I realize that it seems counterintuitive to not give medication that reduces fever to a child in order to prevent seizures most probably caused by fever, but allow me to explain.

When addressing the subject of fever and febrile seizures, it is important to ask two questions: Are febrile seizures worthy of the dread they instill in caregivers and does the routine use of antipyretic medications and non-pharmaceutical measures to reduce fever prevent their occurrence. The answer to both questions is, with rare exception, no. But before I go any further, I must differentiate between classic febrile seizures and children with underlying neurological conditions that predispose them to seizures.

This discussion is about the former. If your child has a seizure disorder or a condition that puts them at risk of having seizures, see the above disclaimer. In fact, everyone just see the above disclaimer. In addition, there is a difference between febrile seizures and seizures that can occur in the setting of fever. A child with a bacterial meningitis can, in severe presentations, seize. This is not a febrile seizure. A child can have fever from an ear infection and have a seizure after getting kicked in the head by a mule. This is also not a febrile seizure. So what is a febrile seizure?

Simple febrile seizures occur in roughly 2-4% of children (this means 96-98% of children will never ever have one) between the age of 3 months and five years during a febrile response to an infection, usually viral in nature. They are seen in this age group most probably because of some immaturity in the developing brain, the higher incidence of febrile illnesses, and the typically higher febrile response as compared to older children and adults. In otherwise healthy children, which is the overwhelming majority of children who have an occurrence of a febrile seizure, it is a benign process that typically lasts seconds to few minutes. The seizures are almost always generalized, meaning they cause abnormal movements from head to toe rather in just one limb for instance. There is a much less common entity known as the complex febrile seizures, but these are rare and do not typically result in any immediate harm either (The long term prognosis is different and beyond the scope of this post.)

So children recover from these very well. Naturally they are a scary thing for an uninitiated parent to experience, and I certainly do not intend to belittle anyone’s emotional response. My intention is to reassure, and hopefully to decrease potentially risky behaviors that result from fever phobia in the future.

Febrile seizures, in the majority of instances, will only happen once to any given child. In about a third of children who have a febrile seizure there is recurrence, but each subsequent seizure is equally benign. And the long term risk of seizures, such as with epilepsy, beyond the febrile seizure age is slightly increased. Which children are at risk? Well, they can occur in any child but they tend to occur in families. It is clear that there is a genetic predisposition in some children, but where that defect lies is as unknown as the particular physiological changes that lead to the seizure activity. The leading theory involves the lowering of the seizure threshold by cytokines, chemicals released in response to infections that, among many other end results, lead to fever. But we don’t understand why seizures only occur in certain children and not others, or why they recur only in some children.

So simple febrile seizures, the most common form of seizures in childhood, do not cause any harm in almost all cases. But they do lead to parental and practitioner anxiety, and they do lead to ambulance rides, ER evaluations, and a large amount of wasted resources in the form of testing and hospital admissions. So shouldn’t we use the wonders of modern medicine to prevent them by lowering a child’s temperature into the normal range? What the normal core body temperature is exactly is fodder for another post (hint, it ain’t 98.6 degrees), but regardless of what a temperature should or should not be, simply throwing an antipyretic or two at it does not prevent febrile seizures. This fact is fairly clear even in children we know tend to get febrile seizures recurrently.

So febrile seizures are pretty much harmless and you can’t prevent them with medication or other measures such as sponging or cold water submersion. Plus, they don’t occur after about age five. Medications such as Tylenol and Motrin are safe, but they are not risk free, and non-pharmaceutical methods do not work to lower fever anyway. There are multiple studies revealing that high percentages of parents dose these medications too high and too frequently, often because of fever phobias such as these. Taking these facts into account, there is no reason to reach for the Tylenol or Motrin, or for a rag soaked in cold water, to treat a fever if your concern is preventing a seizure. The risk clearly outweighs the benefit. There are perfectly good reasons to treat a fever though, and I will discuss them in an upcoming post.

Zebras and the Availability Heuristic…..

During a recent shift, I spent the better part of two hours with a patient’s family discussing the unexpected discovery of a large lesion in their child’s brain. The implications of the finding were grave, and the family was devastated. This was the first time I have made such a diagnosis, and by far the hardest news I’ve had to break in my seven years as a pediatrician. It is an experience that I will never forget, and one I’ve yet to fully recover from at this point.

The diagnosis was, as previously stated, fairly unexpected. There were red flags that appropriately led to the ordering of neuroimaging however. This wasn’t based on a hunch or fear of a lawsuit, as happens far too often in the practice of modern medicine. There was enough concern to go on the encephalic expedition, but the findings were still a shock. My emotional response to the situation was intense and, as often happens, it got me thinking.

In medical school, there is an old adage often passed down by more seasoned physicians that serves to reign in an over imaginative differential diagnosis. When one hears the sound of approaching hoofbeats, inexperienced students are frequently cautioned, one should expect to see horses rather than zebras. Horses, which can be and often are very serious, are common. Horses make the most sense in the setting of hoofbeats. Of course, what is considered a horse may change depending on your location. Measles is a horse in some areas of the world, but it is most certainly a zebra in the United States…..for now. That may change in the future if the anti-vaccine crowd gets their way. But the cranium of the poor child in my above anecdote contained a zebra, a roughly 7cm by 6cm zebra nestled in the left hemisphere of her brain.

When a medical practitioners emerges from such an encounter, they stand at a point of divergence. There are two potential paths that can be taken, and the one which is most hardwired in the human brain is, as is frequently the case, the wrong choice. It would be foolish of me to deny the plain and simple fact that in the practice of medicine our prior experiences inform our future choices. For medical students and residents, there is certainly ample opportunity to learn from mistakes made when caring for ill patients. This is a process that should never end, although the opportunities are hopefully fewer with increasing knowledge and experience.

One potential path, the right one in fact, is one of appropriate assimilation of an emotionally significant and uncommon occurrence into one’s practice. It involves the use of the occurrence as a means of teaching others, of emphasizing historical red flags and abnormal physical exam findings that should lead to reasonable evidence-based testing, and of improving communication with patients and families. And it certainly allows for the experience to serve as an impetus for introspection and growth as a physician and a person. The alternate route, unfortunately, makes more sense. And it seems intuitive considering the horrendous impact on the patient and her family. The ultimate destination of this path is the placement of more importance on personal experience than on objective evidence, and it is a dangerous direction to take.

Prior experience impacts future decisions, of this there is no doubt. But this can be taken to an extreme in the practice of medicine in part because of something described by psychologists as the availability heuristic. What is a heuristic? The term may be unfamiliar, but you have experienced the phenomenon on a daily basis. It is, in fact, an unavoidable and often quite beneficial result of the evolution of the human brain. A heuristic is a rule-of-thumb, a seemingly common sense mental technique, based on experience, that allows for more efficient understanding of our environment. But heuristics tend to sacrifice accuracy for the ability to arrive at a solution more quickly. 

The availability heuristic is a specific example that is frequently employed by physicians. It warps our perception of the likelihood of a diagnosis because we tend to place more emphasis on that which can easily be brought to mind. Emotionally charged experiences are typically the ones we recall most readily. For the remainder of my career, whenever I care for a child with a presentation remotely similar to the one mentioned at the beginning of this post, I will see her face. I will see the face of her parents. I will think of the empty feeling I felt in the pit of my stomach when I heard that the radiologist wanted to speak to me. And I will recall the images on the computer screen which revealed the fist sized tumor in this precious child’s cerebrum. My human nature, developed over hundreds of thousands of years of evolution, will demand action. That action will come in the form of more testing and more imaging. Or will it? Armed with an understanding of how good thinking can go bad, and how the human brain is hardwired to make rash judgements, will I ignore that voice in the back of my head calling for unnecessary testing and imaging, with all of the potential risks that they carry with them? I think so, but I am only human after all.