Shades of gray: Why medicine isn’t always as clear-cut as we’d like

Claire McCarthy, MD

Recently I wrote a blog about how the American Academy of Pediatrics (AAP) thinks that otherwise healthy children with ear infections should wait a couple of days before starting antibiotics, because many will get better without them.

Now there are two articles in the New England Journal of Medicine (here and here) saying that children with ear infections who are given antibiotics are more likely to get better, and to get better quickly, than those who aren’t.

Awkward.

To be fair to the AAP, the studies don’t refute their policy as much as it might seem. In both of the studies, lots of children got better without antibiotics. And since the AAP doesn’t say that kids shouldn’t get antibiotics, just that they should wait, what these studies seem to say is that if parents truly need to do everything possible to get their kids better fast (e.g. the child missing school, or the parent missing work, is a real problem), giving antibiotics is the way to go.

All the concerns the AAP had about side effects (indeed, in both studies diarrhea was common in the kids who got antibiotics) and increasing resistance to antibiotics (interestingly, in both studies the antibiotic used was something stronger, and more likely to cause resistance, than the antibiotic recommended by the AAP) still remain. Both studies acknowledge that more studies need to be done.

But the studies do put me in the position of rethinking, and possibly changing, the advice I give parents—the advice I gave rather publicly just a couple of months ago.

Like I said: awkward.

This actually happens all the time. Doctors rely on scientific studies to tell us how to practice medicine. The thing is, scientific studies are much less clear than people realize. The way a study is designed affects everything, as does how many patients were in it (lots of patients is always better, but it’s not always easy to get lots of patients in a study), how long it lasted, and lots of other factors.

A study can seem to show clearly that X is the best treatment for a condition, so we all start doing X…only to have the next study show that Y is much better than X…only to have the next study show that neither is a good idea and that we need to go back to the drawing board.

“For what it’s worth, we doctors want to be authoritative. It’s much more comfortable and comforting to have The Right Answer. But The Right Answer can be elusive.”

When I started being a pediatrician a couple of decades ago, we were taught that if a baby was at least 9 months old and weighed at least 18 pounds, it was okay to switch from formula to cow’s milk. Now we know that starting cow’s milk before 12 months can lead to iron deficiency, and would never give that advice. Another example: We used to tell parents that it was a good idea to get their baby boys circumcised, because it lowered the risk of urinary tract infections and penile cancer. Then specialists studied the issue and decided that the risks of the circumcision itself (like bleeding or other complications) just about equaled the risks of infection and cancer. So the advice changed: we told parents to make the decision based on personal or religious preference, because there wasn’t a good medical argument either way. Now, with more and more evidence that circumcision may help prevent HIV infection, we may change our advice again.

Parents want their doctors to be authoritative, to tell them exactly what to do. For what it’s worth, we doctors want to be authoritative. It’s much more comfortable and comforting to have The Right Answer than it is try to explain that medicine is art and shades of gray, influenced by an understanding of science that is always evolving. But The Right Answer can be elusive sometimes.

So cut us doctors some slack the next time we hesitate, or waver, or even contradict what we said last year or last week. Understand that it’s not that we don’t know what we’re doing—it’s just that we are learning new things all the time. When we offer you options, understand that the reason we’re doing that is not to confuse you, or to get out of making a decision, but because there truly are different options and the science can’t tell us yet which is best.

The practice of pediatrics is not unlike the practice of parenthood: full of uncertainty, impossible to understand completely and done best when the child is more important than anything else. We’re coming at it from different places, but we’re in this together.

  • http://twitter.com/adenacb Adena Cohen-Bearak

    great post! thanks for your honesty. as a patient, I find it easier if the physician acknowledges this.

  • Melanie Palmieri

    Thank you Dr. McCarthy! I always look forward to your blogs and being a Mom, to your honesty and sense of humor!

  • Sam

    Just had this happen to me today – took my son to his pediatrician with ear infection and her advice was to wait a few days and not treat right away…She did hesitate, but since it did not borther him, advised us to wait.

  • Andy

    You know what I love, which I’ve always been told at Children’s is “you know your child best..” My pediatrician likes to point out that in Europe, they don’t treat ear infections. I will ask for antibiotics if it seems my child is in pain. If not, we do the wait a few days thing. And I have experienced the changing tides and contradicting advice. When my daughter was born, we were told to clean her belly button stump with alcohol. When my son was born three years later, we were told to leave it alone. Recommendations for many things change all the time. I don’t blame the physician.

    Obviously, we look to our physician to be the authority, but as parents, we should have some input based on how we know our children. And I of course mean minor things. When my infant son needed open heart surgery, nobody was looking for me to chime in!

  • SassyMama

    I have 4 young children and have recently moved to a new area. Our 3rd child has always been the one to get sick a lot and just wouldn’t gain weight. She has chronic constipation but the answer was always an OTC laxative and essentially telling me I needed a chill pill. While her siblings track along the 95th percentile for height and 60th-75th for weight, she is at the 70th for height and anywhere from 5th to 25th for age. For years now (she is 7) I have asked her pediatrician’s to run tests and always get brushed off. My mama senses just told me something wasn’t right. Finally, with this move and a new ped they ran the test I asked for, a celiac panel. Calories were going in in the appropriate amount, but yet she is skin and bones. That, combined with chronic GI issues, led me to believe asking for celiac serologies was not unreasonable. Lo and behold, I was right. It was positive and the biopsy is next week. When the pediatrician called me with that news I had a lot of questions. You know what the very best thing she said to me was? “I don’t know.” I was grateful to hear “I don’t know!” She sent me on to a GI clinic at our local pediatric hospital where I know I will get the answers to questions about her symptoms. I loved that she didn’t do what others had done. She gave me the basics and reminded me she is a pediatrician and not a GI specialist. As a mama, “I don’t know” is honestly appreciated at times! I don’t expect my doc’s to have all the answers! I do expect them to know what they don’t know. I’m okay with it not all being black and white, just talk to me about it! I’m a smart lady and appreciate a doctor who won’t “dumb it down” for me. Give me the reasons for it being gray and I have no doubt we can agree on a good treatment plan for my child.