Decisions, Decisions

I was at a wedding talking with another ER doctor. Of course, our conversation turned to “shop talk,” him telling me of a case where he agonized about prescribing a patient a certain medication. I tried to not make light of his worry and to be sympathetic. As doctors, we can sometimes worry about all sorts of things. Even what may seem to be the smallest decisions can nag at us and give us trouble sleeping. It’s because we care so much about our patients and the field of medicine!

We love easy medical decisions. Strep test positive: prescribe Amoxicillin. Elbow dislocated? Put it back! But hard decisions weigh on us. For instance, I see a lot of kids with belly pain sent from walk-in clinics, leaving me to determine if it’s Appendicitis? Sometimes it’s easy- the child’s history and physical exam clearly scream stomach virus and I send them home. Or if the exam shows clear evidence of Appendicitis, call the surgeon. But many have symptoms like a stomach virus and like Appendicitis too. The only way to know better: a CT scan. However, CTs use 500 times the radiation of regular X-rays. Thus if you did the CT and found Appendicitis, you decided right. But if the appendix is normal, you unnecessarily raised your patient’s cancer risk by a tiny, but measurable, amount.

Many take the easy way out and test away! Get sued for not doing a CT and missing Appendicitis? No thanks! However, studies show clearly that patients who get more tests do worse than those who are tested sparingly- more complications, less satisfaction with care and equivalent survival rates. Thus, a movement in our profession called Choose Wisely. This is a movement to get providers to trust their own judgment, do fewer tests and give fewer medicines. Examples of Choosing Wisely: fewer CT scans for head injuries and belly pain; no cold medicines for children (they don’t work); no antibiotics for viral illnesses like colds.

I’ve come up with a new rule I’m trying out on my residents and any practitioners. It’s this: if you prescribe the antibiotic Azithromycin to kids, you’re making an error of judgment. Don’t do it!

Here’s my reasoning: most kids who get prescribed Azithromycin have runny noses, maybe fever, maybe hints of ear infection, and the practitioner wants to cover their bases for all possible bacterial infections. However, these infections are almost always viral. Antibiotics won’t help. If there is a bacterial infection, Azithromycin isn’t the best choice. Looking back at my practice (I’ve seen more sick children than most), I haven’t ordered it in years. I only prescribe it with a positive test for the specific bacteria it covers.

Another reason providers prescribe it is the perception that parents want something, anything that might help. That’s sometimes true, but also, parents want answers. They want a specific diagnosis, they want to know their child will be okay. This palpable urge from parents push doctors to not only prescribe unnecessary medicines like Azithromycin, but to do more tests, as we discussed above.

It may seem counter-intuitive, but Science shows that patients who get more tests and more medicines don’t do better than those with carefully chosen testing and medication. In fact, those over-tested-andprescribed-patients often do worse. They feel worse and don’t live any longer either.

We discussed above the movement within medicine to Choose Wisely- fewer CT scans, no cold medicines, fewer antibiotics. Parents can choose wisely too. They can ask practitioners for reasons for tests and prescriptions. Will this test change our patient’s management, or are we just treating our own uncertainty? Will this medicine really make my kid better, or are we just “covering” ourselves with antibiotics? If it’s Azithromycin, you know the answer!