Tuesday, December 21, 2010

Lessons from my daughter's fever

My daughter has not been well for the last 14 days. She’s been running a fever of about 100- 102 F – and this has been worrisome as a parent. As a doctor , I have learnt quite a bit about how healthcare works ( and does not). What have the lessons been ?

As with all illnesses, we hoped that the fever would be self – limited and would settle down on its own. We therefore treated it symptomatically, with masterly inactivity. My wife is now blaming herself for not doing anything for 4 days. However, I think this was the right decision. If we start treating every fever, then we’ll end up wasting time and money on overtesting and overtreatment. Fortunately, the body has quite a bit of its own wisdom and most problems are self-limited. Of course, we have no way of knowing in advance which fever is going to break on its own; and which one is going to be persistent, so there’s no point in beating up on yourself in hindsight. This again re-emphasises the role of the family as the primary medical care giver !

Since both my wife and I are doctors, we tend to be quite conservative and not over-react. However, when the fever persisted for more than 3 days then we did what every good patient should do – we consulted our family physician. We did the basic tests – and these all turned out to be normal, so we started empiric treatment with antimalarials and antibiotics. The fever broke, so we were all relieved – but then it came back again, so we needed to escalate.

This is when we realized how limited our diagnostic tools are ; and how difficult it is to make a diagnosis of such a common problem ! “ Fever panels “ ( a series of tests which labs provide) are fine if they are positive, but a negative test means nothing. Thus, she could have malaria, and we cannot rule this out just because the smear test is negative. This can be very frustrating – for both doctors and patients.

We took her to an internist, who did a marvelous job. He took a concise history; summarised the story of her fever in 3 lines; explained his plan of action; told my daughter what to do and what to expect; and reassured us. In about 15 min, he had completed his examination and assessment . His working diagnosis was made and we needed to run some more tests to confirm this. He selected an appropriate antibiotic and explained why he had chosen which one he did. He was an excellent clinician , and we were very happy with him ! ( However, even though he is an academic physician, I did notice that he did not have an electronic medical record. This means that he really has no way of critically analyzing the records of all the outpatients he has seen over the last 20 years of his practice , so that all his wisdom will remain clinical judgment, but will not be rigorously documented. )

As it turned out, coming to a diagnosis was surprisingly important. This label gives you a handle around which you can organize your thinking. Are we on the right track ? Are we missing anything ? How long will she take to get better ? What’s the prognosis ? Will this affect her studies? Even if the diagnosis may not be correct , it still provides a useful tangible end point around which medical care can be organized.

The internet was a bit of a disappointment because there was very little information on the management of fevers in India. This is a shame , because this is such a common problem , and there are so many worried patients looking for information. While there is a lot of information on typhoid fever and the antibiotics used for its treatment, not much of this is India-specific, so that one has to keep on reading between the lines . Why haven’t Indian doctors taken a more proactive role on educating their patients online ?

I do hope a clever young doctor will provide this very useful service. It could be a very simple guide for patients but would hold their hand and walk them through their next steps. When to worry; When not to; What tests to do and when; When to get a medical consultation; When to panic

Medicine still remains a combination of science and art – clever doctors use a mix of both to help their patients to get better !

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