Wednesday, June 16, 2010

Watchful Waiting: A Powerful Diagnostic Tool

Childhood is full of self-limited illnesses. Kids get sick and kids get better. The majority of childhood illnesses will get better on their own. Because of this, observation and "watchful waiting" is often the most useful diagnostic test at the pediatrician's disposal.

Parents are often confused about the need for testing. Their experiences with adult medicine is typically full of lab tests and imaging studies. Unfortunately some parents equate the quantity of testing with the quality of care. Choosing observation is often viewed as not caring or not taking the complaint seriously. So there is an intrinsic struggle between what the pediatrician feels is needed, the parent's expectations, and the risk if something is "missed." The skilled pediatrician can navigate this rocky road and have happy parents and good outcomes. This is the art of medicine.

Why not order more tests?

There are several reasons why ordering blood test or x-rays is not always the best choice. Testing often leads to false positive results, which often leads to more testing. This runs up healthcare costs and puts kids through unnecessary procedures. Test results often do not change the management of the child's illness. If the same course of action is going to be recommended whether a test is positive or negative, the test has no value to the child's management. Finally, testing can have negative side-effects. A needle brings on anxiety in children and it hurts. X-rays and CT scans expose children to radiation.

It is estimated that 1 child out of every 1000 to 5000 children receiving a head CT scan will die from cancer attributable to the radiation from that scan. This cancer would likely show up decades later, but the process was started with that radiation exposure. Pediatricians see children who fall and hit their head or who complain of headaches almost daily, giving ample opportunity for ordering CT scans and possibly causing a cancer later in life. Even the most anxious parent would likely accept watchful waiting given these numbers.

Is there a time when testing should be done?

Absolutely! Technology has given medicine the power to diagnose, treat, and cure illness, and there is a time when it should be utilized. If a toddler is in a car wreck, hitting his head and losing consciousness, and now he is vomiting excessively, he absolutely should receive a CT scan of his head. Cancer risk be damned. Physicians are taught to balance the risk of doing something versus observation, and sometimes the scales lean dramatically in one direction or the other.

Trust and communication.

Trust is a crucial part of this equation. The parents need to trust the doctor's skill and the doctor needs to trust the parent's capacity to observe and detect signs of a worsening condition. The doctor must be able to communicate warning signs and parents need to feel free to contact the physician with questions or concerns.

With modern medicine there has been great leaps in technology that have enabled us to do things once unimaginable, yet watchful waiting remains the most powerful diagnostic instrument that the pediatrician has in his or her bag.

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