Using the Wrong Tool
In an interesting study in JAMA thousands of visits to primary care physicians were studied. Progressively through their shifts in the clinic, physicians were more likely to give antibiotics to patients for conditions that did not warrant their use. By the end of the day, patients were about 25% more likely to get unnecessary antibiotics. Typically antibiotics are given unnecessarily for infections that are caused by viruses- such as a viral bronchitis, acute sinusitis, and ear infections (for which we have far better antibiotic-free treatments). The authors commented on “decision fatigue”- a phenomenon where decision makers get tired and make “easier” decisions as their work day goes on. This is a known problem in our court system where a judge is progressively more likely to deny parole as their work day drags on.
In fact, one of my patients had a thought-provoking experience with antibiotics. She had a condition after a known viral infection where a lymph node rose up. She was initially taken in to a pediatric ER and received multiple scans and tests. Aside from serious stress, poor bedside manner- per mom the pediatrician emphasized the risk of cancer, the cost of this work up was over $1000. Clinically this patient was a well appearing child with a small swollen node- no fevers, no redness, no fluctuance (where you can feel fluid inside usually indicating an abscess). She was given first one antibiotic then another was called in 12 hours later. Fortunately the mother contacted me and we held off on these unnecessary treatments. In my new model of care I will be available to head off such events. I was able to make a home visit and reassure that in cases like this we can watch. I can not say that the pediatrician did anything wrong in this case as they were following expert consensus guidelines in treatment and work up. But I do think we should question this management pathway.
By the way the likelihood of a cancer in a child with a swollen lymph node is quite small- about 0.4%- though we should always have every diagnosis in mind. Children are especially prone to inflammatory events as their immune system responds to their environment. A humanized view of the developing child respects this process. Giving medications that can cause allergic reactions, adult obesity, shifting gut biome and diarrhea does not seem like “an easy choice” to me. It is true that “expert consensus” allows for antibiotic prescribing in a case such as this one but my preference would be to base this on clinical presentation and have close follow up. It is time that medical professionals reconsider their expert opinion about initial antibiotic use for lymphadenitis. A more reasonable approach would be to mirror the management options for ear infections where watchful waiting is a viable option in cases that are clinically reassuring.