
‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics - DanBC
https://ep.bmj.com/content/early/2018/02/28/archdischild-2017-313199
======
kashprime
Emergency doctor here, I have to say that diagnosing a sick child is one of
the hardest things you can do in medicine (aside from figuring out why someone
is feeling 'dizzy'). The limiting step here is that we can't do blood tests
and x-ray/CT on everyone that walks in the door (which itself can lead to
harm: [https://emergencymedicinecases.com/overinvestigation-
emergen...](https://emergencymedicinecases.com/overinvestigation-emergency-
medicine/))

I work in one of the busiest ER's in Canada, and maybe one child out of
hundreds will have something hidden... Many illnesses, particularly
meningitis, are so rapid in killing the patient that you may miss the early
symptoms (which are often mild).

What many posters have eluded to about 'gut feeling' is well described in
medical education literature, where 'system 1' is well thought out,
algorithmic reasoning, and 'system 2' is pattern recognition and based on
experience. Many cognitive biases can affect both meeting (described will in
this paper:
[https://www.ncbi.nlm.nih.gov/m/pubmed/12915363/](https://www.ncbi.nlm.nih.gov/m/pubmed/12915363/)).

Your gut feeling can be affected from anything from unusual vital signs, to
the way a patient talks, to beads of sweat on their forehead, and a million
other things that take years and years of training to catch.

Anyone who can build an ML model to catch these clues is going to make
billions.

~~~
philipodonnell
> Anyone who can build an ML model to catch these clues is going to make
> billions.

You'd be surprised. IBM poured billions into Watson and appears to have been
pretty successful in nearly reaching parity with a certified oncologist, but
the results were dismissed because it didn't outperform them.

> At first, Manipal used Watson to recommend treatment options for all cancer
> patients, said oncologist S.P. Somashekhar. It found the software agreed
> with doctors most of the time, so Manipal stopped using Watson on every
> patient, he said.

[https://www.wsj.com/articles/ibm-bet-billions-that-watson-
co...](https://www.wsj.com/articles/ibm-bet-billions-that-watson-could-
improve-cancer-treatment-it-hasnt-worked-1533961147)

~~~
freeone3000
That's not a great definition of parity. We'd want accuracy and specificity
numbers linked to outcomes, not concurrence. The times when Watson agrees with
doctors is effectively irrelevant - results would be the same whether or not
he was added. We need to highlight whether, given a disagreement, Watson was
better or worse for outcomes.

~~~
philipodonnell
The trick is whether the cases of disagreement were themselves predictable!

Given a fixed number of oncologists and deploying Watson only to support those
oncologists, yes, you're correct that its only useful if it outperforms them.
But I think of it more like Watson is a single hive-mind team of like a
thousand med students near the end of residency: they get most things right
but there are a few places where more experienced doctors will be better,
though the scale with the hive mind is far higher.

You have one of two reactions to that. 1) Hire fewer senior oncologists and
have them focus on the more difficult cases and leave the hive-mind to deal
with thousands of routine cases, or 2) ignore the hive mind until its
literally better than a typical senior oncologist.

The medial profession seems to repeat this cycle of "only full doctors can do
anything because even seemingly routine cases might be hiding something more
serious" to "maybe some routine things can be done by people with less
training and full doctors should focus on the more difficult cases". See nurse
practitioners, dental assistants, and, in my mind at least where we are going
with things like Watson.

~~~
Bartweiss
I think part of the problem for Watson is that it needs someone to gather the
data, which is usually a doctor. So if you're pairing each patient with an
oncologist for intake _anyway_ , it's not clear that "examination plus enter
all data into Watson" is a benefit over "examination plus make a decision".

I guess the ideal outcome for Watson (if it doesn't outpace expert
oncologists) would be something like "experience nurse practitioner does an
exam, and enters data into Watson" or maybe even "special oncology-trained NP
does an exam with Watson".

The other part I don't know is what oncology accuracy rates look like. If the
reason to not majorly expand screening is cost and availability, Watson could
be huge. If it's false positives from our existing rate, there's a lot less
value.

~~~
freeone3000
Let's look specifically at mammograms. (Stats from CTFPHC, a division of PHAC,
part of the Canadian government.)

[https://canadiantaskforce.ca/tools-resources/breast-
cancer-2...](https://canadiantaskforce.ca/tools-resources/breast-
cancer-2/breast-cancer-risks-benefits-age-40-49/)

Wider screening isn't great. Essentially, people with medical problems self-
select pretty alright already, and wide early-screening initiatives for most
cancers introduces as much or more false positives (that persist through
screening!) than actual cases of cancer it catches - and moreover, it's not
even clear that the early screening is _effective_ \- the false negative rate
is high enough that the overall incidence of advanced cancer is unchanged even
with early screening. (Bleyer and Welch, NEJM, 2012)

Basically, we need better screening, not more screening at our current levels,
and it's not clear whether watson can provide that.

~~~
Bartweiss
Precisely - since mammography is the standard "counterintuitive Bayes rule"
primer, I remembered those numbers don't support wider screening.

I'm not discounting the possibility of a useful role for Watson in wider
screening, but it's not clear to me where it would be. If it happens after any
kind of extensive examination, doctor-hours are being committed regardless and
there's little gain. If it happens at a population-level screen like
mammograms and colonoscopies, "almost as good as oncologists" isn't enough to
add any value.

------
throwawaysadly
This hits close to home for me. My 3 year old daughter was recently diagnosed
with a rare form of cancer (with a rather poor prognosis).

We brought her to a pediatritian in two states, both thought it was nothing
but "growing pains". Her limp got worse, she was in incredible pain for days.
She would develop fevers with no other symptoms.

She would mysteriously get better, then a month later it would happen again.
Each time it got worse and her pain increased, the limping was more
pronounced.

They misdiagnosed her and wanted us to see a specialist for it. We refused to
wait a couple months to get an appointment with one and demanded to see
someone, anyone else.

We eventually got to see a doctor (not a pediatritian) that at least done
their done and ordered proper tests. Unfortunately they found bone lesions.
Upon closer inspection they found a primary tumor in her abdomen, the cancer
has already spread to her bone marrow (hence the bone pain/lesions and
limping).

She's doing pretty good now-- still along ways to go for treatment though.

All in all-- as a parent you need to follow your gut and don't trust
everything doctors say or feel. We lost a few months due to poor pediatricians
that couldn't do their job (these were pediatricians at well known places).

~~~
rendaw
Not pediatrics, but I had hand issues and went to a handful of doctors over
the couse of two years who dismissed me after poking or prodding my hands a
couple times.

AFAICT there's no way to _know_ a doctor has experience and wisdom, but it's
crazy that doctors won't even order relevant tests done. It's not a matter of
costs - all they need to do is ask first.

In the end I went to the Mayo clinic in Minnesota where they performed a
thorough battery of tests and gave me a proper diagnosis within a couple days.
If you're at your wits end, at least I can recommend them as being diligent.

~~~
Cthulhu_
My GF's gone through the same windmill, over the span of seven (or more) years
before finally getting a diagnosis. Multiple ones actually.

Her abdominal pain issues and discomfort were blamed on period pains first,
then IBS (because her mother has that too), until finally, after she herself
asked for it, she was diagnosed with endometriosis (and an ultrasound revealed
a 10cm cyst).

Likewise, she's struggled with being punished for being a naughty child during
her upbringing, school problems, and later depression and suicidal tendencies
when put on medication for either depression or birth control. It was only
once her son was diagnosed with ADHD that she recognised those symptoms and
got herself a similar diagnosis. Both are on proper medication for that now
and it's a huge improvement for both.

TL;DR there's still a lot of ailments that aren't easy to diagnose.

~~~
groby_b
Your girlfriend also made the "mistake" of being a woman, and I wish I were
kidding about that.

The fact that "borderline histrionic" is diagnosed much more often in women
echoes back to the Victorian diagnosis of "hysteria", and pain reported by
women is often discounted.

And unfortunately for her, ADHD also falls into the category of doctors
ignoring women. It's slowly getting better, but essentially, all diagnostic
tools were tailored to boys, and the first studies for girls' symptoms were
beginning to come out in the early 2000s.[1] If you read that article, you'll
also find that her way to discover ADHD is common for women - you find out
because your child is diagnosed.

It's not only that ailments are hard to diagnose, it's that most medical
research is tailored towards white males. (And most experiments are geared
towards the college age group, due to ready availability).

The further you're outside of that group, the more work you'll have to do on
your own.

[1]
[http://www.apa.org/monitor/feb03/adhd.aspx](http://www.apa.org/monitor/feb03/adhd.aspx)

------
dagw
I think another solution is forcing doctors to work more off of check lists
and less following their gut.

When I was a baby I also had some weird symptoms and my mother took to be
several pediatricians who couldn't identify the problem. Eventually one
evening my mother ended up in the emergency room with me and got to see a
really nervous young doctor who, as my mother describes it, it felt like we
where the first patients he'd ever seen on his own. Anyway this 'kid'
literally had a folder with lecture notes on his desk and worked through them
step by step and ordered the right tests and nailed the diagnosis on his first
try (which fortunately turned out to be nothing serious).

So as much as it's vital for parents to follow their gut, I feel like doctors
often just follow their gut far too much and need to take a more rigorous
approach to diagnostics.

~~~
anomatopoeia
Similar situation, our sick child was passed off by initial doctors as having
something minor. We were fortunate to try a different ER where a nervous young
doc took a more skeptical approach and ran down the checklist fully before
correctly diagnosing with bacterial meningitis. The doctor had never even seen
a meningitis case before.

Per discussions with the infectious disease specialists this timely diagnosis
likely saved our child's life.

------
roenxi
Let us reflect that medical practice is one of the textbook examples for
people making bad decisions due to Simpson's paradox. That the sheer number of
highly opinionated people who are confident and wrong is staggering (take
nutritional information, for example). That the risk of being embroiled in a
good game of political or legal football is high.

On top of that, this is a field that historically has had poor exposure to
good engineering practice or mathematics. A field where a researcher's have
both the intelligence and lack of exposure to plausibly rediscover integration
without being clued in by anyone in the know [1].

There is almost certainly more to be gained by working with evidence and solid
statistical practice than there is by gut and guessing. It is hard enough just
keeping everyone focused on the measurable evidence and weeding out stats
mistakes without pretending that doctors should somehow diagnose based on
their 6th sense. That isn't a healthy expectation for any party, including the
doctor.

Efforts should be made to figure out what variables they are actually using to
make decisions, if those variables are actually useful predictors and then how
to systematise them. It is tautologically impossible that an experienced
clinicians is detecting undetectable variables in their decision making
process.

[1]
[https://academia.stackexchange.com/questions/9602/rediscover...](https://academia.stackexchange.com/questions/9602/rediscovery-
of-calculus-in-1994-what-should-have-happened-to-that-paper)

~~~
VLM
"the risk of being embroiled in a good game of ... legal football is high."

That's my personal experience as a parent, unless the pediatrician can
absolutely rule out all possibility of any theoretical disease then all
conversations with the pediatrician's office always end with an official
recommendation to CYA by spending a day at the ER.

Two anecdotal heat exhaustion cases:

Me, like a quarter century ago, in the Army after setting a new personal
record on a daytime hot summer windless humid PT test while stationed
temporarily in the deep deep south; typical heat exhaustion, no energy, puke,
dizzy, gray world, squadmates turned me in for "wobbling on my feet too much".
PS and medic look at me, "well, you're still sweating, so ..." dump a canteen
of water on my head and torso, force me to drink a canteen of water, wait to
see I don't puke for a couple minutes, escorted by another soldier to sit in
front of an air conditioner with him ordered to watch me drink another canteen
of water for an hour. Treatment cost approx five minutes of medic labor and
one hour of chaperone solder labor to observe me while I recovered, and three
canteens of drinking water.

Preteen daughter gets heat exhaustion on the hottest most humid day of the
year after a long day working hard outdoors despite being well hydrated, no
energy, puke, dizzy, but still conscious and sweating, wife gets nervous
resulting in call to pediatrician resulting in spending rest of day and most
of night in the ER running EKG heart tests and blood tests and MRI the skull
looking for tumors. She wasn't even dehydrated enough to need an IV, so they
actually treated nothing, merely immense amounts of diagnostic screening to
rule out every possible ailment that could cause dizzyness (which seems to be
practically everything). Treatment cost in the five digits, paid by everyone
else via insurance premiums. But, at least the pediatrician CYA from legal
standpoint.

To some extent the real cost of "malpractice insurance" isn't directly paid as
"malpractice insurance" but is funded by immense insurance premiums.

I looked it up for fun and the odds of a teen girl being diagnosed with a
brain tumor is approximately one in ten thousand per year; the odds of a teen
girl getting dizzy on the hottest sweatiest day of the year after working hard
outdoors is somewhat higher, but legal CYA is very expensive.

------
mrkgnao
> Physiological values are complex in paediatrics. They are more than
> complicated because although there are published ‘normal values’ which will
> guide the clinician in knowing whether a child is tachycardic or
> tachypnoeic, these are in fact reference ranges that were initially based on
> expert opinion. Although meta-analysis shows these reference ranges to be at
> least somewhat valid, it is probably safest not to think of them as ‘normal
> ranges’ at all since much of the data includes children in abnormal
> circumstances. _Indeed, the clinician who relies on these values will by
> definition be unlikely to have a ‘normal’ child in front of them._

Relatedly, I'd imagine that (akin to the story about choosing what parts of a
fighter plane to armour) the worst health emergencies, esp. in children, are
the ones where the child does not make it to the ER alive or is either
unresuscitable (word?) or deteriorates rapidly and uncontrollably before a
diagnosis can be made.

~~~
edanm
Yes, but I assume that all children who die in e.g. the States will
automatically get an autopsy and a cause of death will be determined, no?

(Note: haven't read the article, so I'm not sure if I'm contradicting anything
here or just agreeing with it!)

~~~
epmaybe
No, generally the parents have to request an autopsy. The provider can always
recommend getting an autopsy, or requesting one, but ultimately that decision
lies with the parents.

------
DanBC
The title was too long, so I took off the quote marks.

'So why didn’t you think this baby was ill?' Decision-making in acute
paediatrics

I'm submitting this because people on HN are interested in cognitive bias, and
this paper discusses biases in the context of healthcare.

------
java-man
There is probably something wrong in the way medicine is being taught. Unlike
physics, medicine might be still a largely empirical occupation, devoid of
rigorous experimentation and evidence based science.

It is slowly changing. For many years, the cause of peptic ulcers was thought
to be stress - countless doctors repeating this mantra to the patient. It took
a heroic act of Barry Marshall [1] to conduct an experiment (on himself) and
demonstrate that it is, indeed, false, and identify the root cause.

I wish we approached medicine more like physics and less as a closed and
secretive (and lucrative) skill.

[1]
[https://en.wikipedia.org/wiki/Barry_Marshall](https://en.wikipedia.org/wiki/Barry_Marshall)

------
rsync
Much attention (because Taleb) is given to "having skin in the game" \- and
rightly so. It's an important and actionable heuristic.

Also of tremendous import is "gut feeling" which is called out specifically in
the article:

"Gut feeling has been defined as an intuitive feeling that something was wrong
even if the clinician was unsure why."

The disorganized, indescribable, cumulative knowledge of a _human_
practitioner who has seen thousands of cases is so valuable that it should be
given very particular nomenclature and afforded tremendous esteem - even more
so than the physicians with their decades of schooling.

~~~
Fomite
I work with a lot of physician colleagues (as well as veterinarians) and one
of the things I wish we could capture was what words someone uses to trigger
those gut feelings. The way a patient describes their pain, how we try to wrap
our language around complex disease concepts...

~~~
sametmax
If you are focusing on words, you are missing the big picture. 'Guts feelings'
are what you get when your brain process a butt load of informations in a
fuzzy way. This includes subtle smells, colors, moves, timing, shapes, sounds,
chain of events and how they interact with each others.

Words can be a tiny part of it, but usually gut feelings are about all those
things you can't process as easily with rational thinking and so rely on a
different, less precise and more general, method of analyzing. This does not
play well with language, which is very accurate and precise, very
intellectual.

It's why we can easily walk, but have a hard time describing how we walk.

A commenter on HN talked about the book "The inner game of tennis" not so long
ago. I highly recommend it to get a gentle introduction to this part of us.
Especially on this site, where a lot of us are geeks who are more used to
leverage their rational thinking than their feelings.

Last year, many commenters talked about meditation. While I do recommend the
practice, starting from the sport point of view is way easier to swallow and
make a better starting point for people with strong affinity with precision
and step by step logic.

~~~
DanBC
The gut feelings a health care professional gets will vary based on the
language the patient uses.

The gut feelings a doctor has to a patient saying "I have crushing chest pain"
will be different to the patient saying "I have burning chest pain".

~~~
scoot
Your example perhaps doesn’t lend itself to a discussion of “gut feelings”,
since it describes different symptoms quite specifically. In the absence of
other information, the first sounds like a heart attack, the second, heart-
burn (acid reflux).

Gut feeling relies on more abstract concepts, particularly in the context of
pediatrics where a child may be unable to verbalise their symptoms.

~~~
Ntrails
I agree the specific example is somewhat explicit, but the point being made is
valid. Whether it's a subtle choice of words, lack of eye contact, or constant
fidgeting. They can all have some additional meaning (or none!).

One example that I've heard is common is about reading body language that
might indicate discomfort in talking about a subject, which might suggest
under/mis-reporting of an issue.

------
walrus01
As a non medical professional, I can't even imagine the difficulty in trying
to diagnose a severely sick child that is too young to speak or articular
symptoms/where it hurts... Scary.

~~~
Fomite
One of the things my veterinarian colleagues talk about a lot is how do you
make a diagnosis with "My chicken is acting funny" as the only information you
have.

~~~
taneq
"My car's making a funny noise."

"My computer's acting weird."

~~~
nerdponx
But you can't take apart or reboot the chicken.

~~~
tialaramex
And this is why I write software for a living. Because "Take the chicken to
pieces to find out why it's broken" makes sense to me, so I'd be a rubbish
chicken doctor.

~~~
lmkg
From what I understand, that actually is common for chickens because they're
usually livestock rather than pets. If one chicken might be sick, you care
more about whether it's contagious than the outcome to the one chicken, so you
do the most thorough diagnostics you can even if that requires an autopsy.

Now dogs on the other hand...

~~~
Fomite
I like working with vets for my stuff (epidemiology) because there are really
interesting constraints.

As you mention, one chicken is expendable, but you're worried about tens of
thousands of birds.

A sheep is...mostly expendable. You have a low, market driven cap on what you
can spend.

A dog or cat, less so - there's an emotional connection, but there's also an
upper threshold (with a wide range, and who has what threshold is often
surprising).

A race horse...well, let's just say equine ICUs are really pretty nice, all
things considered.

------
gleb
Vets can’t talk to their patients either. I would be curious of how their
approach compares to pediatricians’.

~~~
hycaria
I'd say we have 3 advantages over pediatricians.

First we often deal with adults who are a bit less susceptible to die very
fast than infants, which gives more time.

Second we have the owner's wallet as a set limit. Sometimes you do with what
you're allowed, and one can only go that far with a limited panel of tests or
when hospitalisation is refused.

Third an animal death is more acceptable than a human, let alone a child.

------
alexpotato
I thought that probabilistic decision trees had been around for a long time in
other parts of medicine

e.g. [http://www.seilevel.com/requirements/visual-models-save-
live...](http://www.seilevel.com/requirements/visual-models-save-lives-how-a-
decision-tree-revolutionized-heart-attack-diagnosis-2)

So I'm surprised there isn't a general one for paediatrics.

------
amelius
Medicine seriously needs a data-science approach.

~~~
epmaybe
can you elaborate on that? I'd love to hear your thoughts.

~~~
amelius
Well, it's quite simple.

Right now the quality of a diagnosis depends heavily on the experience of the
doctor. One of the problems is that even an experienced doctor has little
experience with rare conditions.

In this age of data-science, we can replace the doctor's diagnosis with a
number of standard diagnostic tests (observations), which can be performed by
a nurse and/or lab-worker. The diagnosis is then determined based on
"correlation" with a data-set, collected over an entire population.

The best possible treatment plan can also be computed based on this diagnosis
(which could be more refined than a doctor could possibly make, because it can
work with probabilities instead of a single outcome).

