Question medical over testing and over treatment of your children

Working in the ER, I regularly get asked by worried parents to send more tests or to do more intervention on their child  "just in case" and for their own peace of mind. When the requests are medically unnecessary, I do my best to dissuade parents. Most times, I am successful, but sometimes, parents' minds are set.

Physicians struggle with this every day. Today, perceived quality of healthcare delivery, and often, physician compensation, are dependent on patient satisfaction.  Comments affecting the rating or "liking" of physicians in social media sites put a lot of emphasis on "how well the physician listens to their patients' concerns," which is often tied to how many tests are ordered, and prescriptions written. I often hear parents complain that nothing was done for their child during a previous visit, meaning no tests were sent. In fact, their child received a full evaluation based on a thorough history of illness and a physical examination. That's all the visit warranted.

What is the problem with over testing and over treatment?  The answer was the heart of a plenary lecture from Alan Schroeder, MD, "Safely Doing Less: A Solution to the Epidemic of Overuse in Healthcare" at the American Academy of Pediatrics conference last fall.  Schroeder, a pediatric hospitalist at the Santa Clara Valley Medical Center in San Jose, Calif., has published many articles in different medical journals challenging overuse in healthcare.

His talk emphasized that current healthcare spending is unsustainable, that unnecessary harm is unacceptable, and that although medical errors and patient safety have emerged as popular topics in medicine, the focus is sometimes misdirected. Despite the fact that U.S. healthcare costs constitute one-sixth of our GDP or 3 trillion dollars a year (more than that of any other developed country), important outcomes such as life expectancy and infant mortality are inferior.

Too much testing and treatment can harm children. When a patient experiences an adverse event from a medical intervention, the focus has been to put processes in place to prevent the adverse event, but few question whether the intervention was necessary in the first place.  Schroeder also highlighted that safely doing less should not be used by parents as a reason for not immunizing their children.

In the ER, some common conditions that often lead to harmful over testing or over treatment of children include fever, vomiting and/or diarrhea, and minor head injury.  For example, a lot of young children with fever come in or are referred to the ER for "blood work" to look for evidence of bacterial infection (bacteremia) in the blood, especially when the cause of fever is not readily apparent. The physician orders a blood culture. The patient endures the pain and distress from being stuck with a needle (sometimes multiple times).  The blood culture sometimes becomes falsely positive one to two days later, from contamination from bacteria present on the skin.  Since the preliminary laboratory report does not readily distinguish between a real infection and contamination, the patient is called back for a repeat blood culture.  This illustrates how medical testing begets further testing. In fact, as long as children are immunized, their risk of acquiring a bacterial blood infection is very low.  The majority of children with a fever have a viral infection, which resolves on its own.

Some parents of children who may have no signs or have signs only of mild dehydration from vomiting and/or diarrhea, come to the ER expecting intravenous fluids, even though many studies have shown that oral rehydration with a balanced electrolyte solution is just as effective. The physician orders placement of an intravenous line and intravenous fluids, and often, a blood test measuring electrolytes. Any subsequent electrolyte abnormality leads to the test being repeated, more treatment to correct the abnormality, or hospitalization, all of which could have been avoided.

Lastly, witnessing a child experience a head injury from a fall, blow to the head, or related to sports, is very anxiety-provoking. Parents, child care providers, teachers, athletic trainers, and coaches, take or send children who experience a head injury to the ER for evaluation. Some ER physicians, either from their own anxiety, or parents' request, indiscriminately order a brain CT scan.  In fact, there are published well-designed research studies that help clinicians identify the small subset of head-injured children at increased risk and should receive a brain scan. Although the risk for subsequent development of cancer from CT radiation is minimal, this risk can and should be avoided altogether.

Why do physicians over prescribe tests and therapies? Besides the drive to satisfy patients, Schroeder talked about other reasons, such as pressure for physicians to not miss a diagnosis, fear of being sued, time constraints, and uncertainty.  Explaining why a test or treatment is unnecessary takes more time than just writing an order or prescription. Uncertainty leads to discomfort, which can lead to over testing and over prescribing.

Like Schroeder, I am optimistic that the tide of healthcare overuse may be turning.  There is a growing movement in medicine to safely do less.  In the forefront is the Choosing Wisely Campaign, an initiative of the American Board of Internal Medicine Foundation, where physician specialty groups list their top five tests and treatments that should be challenged.  This is a good resource for medical providers and patients.  Parents should question the necessity, and weigh the risks and benefits of prescribed tests and treatments for their children.

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