Watchful waiting

Wednesday, February 17, 2010

The art of medicine consists in amusing the patient while nature cures the disease. – Voltaire

When it comes to expectations, there is a major communications divide between physicians and patients. Patients want to be educated and reassured about their ailment while physicians misinterpret that expectation and work too hard to cure what ails. In a pure business model, what a patient wants and needs may not be what they get. Much of that disconnect has to do with experience on both sides of the equation.

The world has become a much smaller place with families spread far and wide. The concept of many family generations living near each other has been replaced by the opportunities t olive and work almost anywhere. Travel has become more reliable and communication across thousands of miles is instantaneous. The need to live next door to a grandparent isn’t as pressing. The downside to this mobility is the loss of generational experience. When a child coughs, vomits or develops a fever, too often there isn’t a grandmother living next door to get a second opinion as to what to do. Without that experience available to help decision making, the parent may call a nurse help line or visit a care provider asking for advice.

The doctor may have a mistaken impression as to why the patient is visiting. In the scheme of things, the most valuable part of a doctor’s visit is the time spent listening to the patient and offering guidance and education. Unfortunately, the physician may feel that the patient has to leave with a parting gift of some sort and many times it is a prescription for a medication, presuming that if the patient does not leave with something in hand, that they are unsatisfied and the visit a waste.

Education takes time and it is a wise physician who takes time to listen to their patient and to answer questions that aren’t even asked. Some situations are universal. If a child is complaining of abdominal pain, the parent wants to be reassured that the child does not have appendicitis. If headache is the complaint, the answer needs to be that the problem is not bleeding in the brain or a tumor. Sometimes the visit is precipitated because of what’s happening in the news. At the height of the H1N1 influenza epidemic with news stories reporting of the serious complications, parents brought their children to be seen for fear that they might die.

For many illnesses, time is the ally and watchful waiting is the key to diagnosis, treatment and recovery.

Fever is a routine symptom in infants and children. It is a normal immune response to an infection to generate an elevated body temperature and make the body inhospitable. That doesn’t mean that the fever should be ignored, but if the child is otherwise doing well, treating the fever with acetaminophen or ibuprofen may all that is needed.

Vomiting and diarrhea can make a person miserable and there should always be worry that if enough fluid cannot be taken in, that dehydration is a concern. The key to treating vomiting and diarrhea is resting the stomach and bowel by not asking it to digest solid food. Clear fluids (anything you can see through like water, clear broth, apple juice, Gatorade/Powerade) taken in small amounts, like a mouthful or two, may be all that is needed to stave off dehydration.

Colds and cough are tough symptoms because they interfere with important things like sleep and can also be easily observed by teachers, coworkers and friends. Yet, there is little to be done to make the runny nose and hacking resolve more quickly than nature can do on its own. Symptom control has to balance the benefits of over the counter medication against their side effects. The American Academy of Pediatrics suggests that cough medications have no place in treatment. In adults who have underlying medical conditions, there may be unintended side effects and reading the fine print on the medication label is mandatory (either that or talking to the pharmacist and getting advice.)

Most bumps, bruises, strains and sprains resolve with rest, ice, compression and elevation. It may be appropriate to seek advice if there is concern that a more serious injury has occurred. That concern may be resolved by the care provider taking a history and performing a physical examination. X-rays may not be needed.

With no grandmother next door to give sage advice and reassurance, patients need to develop their own experiences for guidance. The ability to watch a first born grow and flourish should make the second child a little less frightening. That experience may be tempered by seeing a coworker or friend develop complications from what seemed a routine illness or injury. All fevers are not meningitis, all chest pain is not a heart attack but if there is worry the n a doctor’s visit is appropriate. It is also appropriate for the doctor to make clinical decisions based on history and physical examination that all is well.

It is important to remember that common things are common and that the best treatment may be none at all.

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