April 22, 2022
One of the more common and challenging issues we encounter in pediatrics is when we perceive that we can’t meet parents’ expectations for treatment interventions for their child. Typically this presents to us by way of a cold or flu virus, which can’t be treated by antibiotics, and yet parents want us to do something to help their child feel better. We want to avoid doing more harm than good by prescribing unneeded medications or treatment, but how can we best navigate these conversations? On this Guidelines with Gabi episode, listen to the Kid Experts discuss other options and strategies for navigating these situations with families, and avoid the trap of overprescribing, particularly in high paced, high volume care settings, while challenging our perceptions of parents expectations, enhancing our communications with families and building trust along the way.
Transcript
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for the most amazing people on earth, kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. One of the more common and challenging issues that we encounter in pediatrics is when we perceive that we can’t meet parents’ expectations for treatment interventions for their child. Typically, this is because a child has a cold or a flu virus that can’t be treated by antibiotics. And yet parents are desperate for us to do something to help their child feel better.
We want to avoid doing more harm than good by prescribing unneeded medications or treatment, but how can we best navigate these conversations? On this Guidelines with Gabi episode, listen to the kid experts discuss other options and strategies for navigating these situations with families so that we can avoid the trap of overprescribing, particularly in high-paced, high volume care settings, while at the same time challenging our perceptions of patient expectations, enhancing our communication with families, and building trust along the way.
Speaker: Welcome to Guidelines with Gabi.
Dr. Gabi Hester: Most of us in medicine have had this experience. We’re seeing a patient who wants something that we don’t think they need, something that might actually cause them more harm than good. In some cases, this might be a desire to have a certain lab test done or an MRI scan, but perhaps the most common example is around antibiotics. You believe that the child has a bad cold. They clearly feel unwell and are miserable. And the parents ask you as the provider about antibiotics. While you wish there was something you could do to make the child feel better sooner, what options do you have in your toolbox?
Today I’ll be joined by Dr. Lindsay Hatzenbuehler Cameron, Assistant Professor of Pediatrics and Pediatric Infectious Diseases at Baylor College of Medicine in Texas Children’s Hospital. Colds are caused by viruses, viruses are not treated by antibiotics, and antibiotics can and do have side effects. When I was preparing for this talk today, I came across a study published in JAMA in 2016 by Fleming-Dutra et al. that estimated rates of appropriate antibiotic prescription use in ambulatory settings across the US and found that approximately 150 per 1,000 people received an inappropriate outpatient antibiotic annually. So that was staggering to me. So my question for you, Lindsay, is, are kids being prescribed antibiotics that they don’t need?
Dr. Lindsay Hatzenbuehler Cameron: My answer to that is yes and no. The literature supports that pediatricians, especially those in academic medicine, actually are better at prescribing antibiotics appropriately. And that studies haven’t actually been done in private care settings similar to those settings, but that it’s interesting that depending on the setting, that there are different barriers to appropriate antibiotic use. So studies have supported that those who work in emergency room centers or urgent care centers, that their barriers could be unique and that they actually may overprescribe antibiotics more often.
So some barriers that I can come up with include systematic barriers. So the fact that they’re in a high-paced, high volume setting. They may see a variation in complexity. So you mentioned that colds are caused by viruses. Viruses for the most part don’t have a treatment. So you know that flu has a treatment called Tamiflu. Herpes has a treatment called acyclovir. But for the most part, most viruses have no treatment. So all they need is tincture of time, symptomatic care from that perspective. And that if you see a high level of complexity in the emergency room and a low level of complexity in the emergency room, which would be just the common cold, that it’s hard to treat that variation in patient complexity.
Dr. Gabi Hester: So you mentioned some of those potential barriers related to the emergency department setting itself. So high volume, sort of that busy pace trying to get patients move through. What are some factors that might be associated with what parents or caregivers or patients want or believe?
Dr. Lindsay Hatzenbuehler Cameron: Yeah. I think that that’s one of the cruxes of this issue in the sense of that parents may come in with different expectations than what the provider actually perceives. So there’s some amazing literature out there that is mostly qualitative, and so that pediatricians may not have access to it because they read more quantitative literature to guide their practice. But the qualitative literature actually supports that parents come in with different expectations than what the providers perceive. So the providers perceive that the parent, especially in the emergency care room setting or the urgent care setting, actually wants antibiotics. They want a quick fix.
We as practitioners also potentially want a quick fix, right? So one of my favorite diagnoses in residency was strep throat. So easy. They come with a fever, pharyngitis, abdominal pain, they’ve got petechiae in the back of their throat, we do a rapid strep or a strep test and it’s positive. Super easy, give antibiotics. They improve in 24 to 48 hours. It’s like the quick fix. No one in medicine can argue that a quick fix isn’t something that’s valuable.
But in most situations, kids with viral infections need time to improve. And so the literature actually supports that parents come into the clinic wanting the best for their child. And I would argue that most practitioners actually want the best for the child too, right? And that parents come for reassurance. They want anticipatory guidance. They want symptom recommendations on how to control the child’s fever, why they’re not sleeping, how they can improve their appetite, in addition to when to return to clinic if the child doesn’t improve.
Dr. Gabi Hester: So that perception that many of us might hold that a parent is bringing their child in because they want antibiotics or a certain treatment, that might not be supported by the literature that you’re referencing?
Dr. Lindsay Hatzenbuehler Cameron: Yeah, exactly. And there’s actually some great literature out of the UK that found the same. So Dr. Gerber from the University of Bristol actually has published some neat literature in addition to some resources for pediatricians, including a video that shows like a parent coming in super concerned with all kinds of questions and that the practitioner unfortunately doesn’t address a lot of those questions. They examine the patient. They don’t explain what they’re thinking about. They don’t explain the diagnosis and they give a prescription. And then the mom leaves with a ton of questions.
So this literature, in addition to a neat study that just came out of CHOP by Gerber and his group found that actually parents come in wanting to trust the provider to meet the needs of their child and to ask questions not related to antibiotics. Actually most parents come in not wanting antibiotics. They want antibiotics if that’s what the child needs, but they actually want to trust the provider and want some reassurance.
Dr. Gabi Hester: So in this Gerber study, we learned a little bit more that they aren’t necessarily seeking antibiotics or that specific treatment. Did the study show us what families do want?
Dr. Lindsay Hatzenbuehler Cameron: So I think that the major take home message from the Gerber study was that parents come wanting to trust the provider. So my message to outpatient providers, pediatricians, practitioners, is to stick to your guns, stick to your training, stick to what you know, and explain to the family your thought process and why you feel like the child potentially has just the viral illness. They don’t have a bacterial co-infection or they don’t have a bacterial illness that needs antibiotics. And that families will want to hear your expert opinion.
Dr. Gabi Hester: Are there any strategies that have been really shown to help provide that reassurance to families and help support their needs during that visit?
Dr. Lindsay Hatzenbuehler Cameron: You hit the nail on the head by saying, hey, what do parents need in the sense of ask them? So what are you hoping for today’s visit? And then be quiet. Allow for that open ended question. Just allow them some time to talk and to express their concerns. If they have many, many concerns, ask them to rank them, meaning, what’s your major concern today? What are you hoping from today’s visit? The literature also supports talking through your thought process is very valuable to parents. So if they give you a script, meaning this is what my child has had, so talking through those symptoms. Okay. If a child has running nose, that’s more consistent with a viral illness.
And then talking through potentially your physical exam findings. So when you’re looking at the ear, what do you see? When you’re listening to the lungs, what do you hear? So talking through why you feel like this child has a viral illness and that you’re actually excited that they don’t need antibiotics because it could be just a viral illness that needs supportive care. Because as we know, antibiotics have side effects, as you mentioned earlier in this podcast, and that we don’t want to cause harm by giving something that’s unnecessary.
Plus, there’s lots of wonderful educational tools. So just sitting down and explaining the difference between viruses and bacteria. Explain that most children get better over time when they have a viral illness, and that supportive care is all that they need. Also, just offer some reassurance in the sense, “Hey, I’m here for you. If this child doesn’t seem to improve as expected, please come back.” Offer that level of reassurance on what to expect in addition to a hand to come back to if needed. There are some fantastic resources on the CDC’s website, actually educational resources that are high yield. They have some fun videos as well that parents can watch to teach them about the differences between viruses and bacteria and why antibiotics aren’t always necessary. And so those are good resources for pediatricians to use as well.
Dr. Gabi Hester: Lindsey, over the last 10 years or so of your practice, how do you feel like your conversation with parents and caregivers and patients has evolved in this realm as far as thinking about what the diagnosis might be, and then what the treatment plan would be for a particular situation. How have you evolved in the art of that conversation over time?
Dr. Lindsay Hatzenbuehler Cameron: I do feel like I’m a lifelong learner in the sense of that I have lots to learn still, but I think over time and practice and seeing a lot of different patients with varying complexity, in addition to different parent groups that have different needs, that I think that what’s improved the most is my ability to communicate with them. Making sure that I do use open-ended questions, open communication with them. Addressing their needs, meaning they say, “Hey, I think my child has pneumonia. Do you agree?” And talking through why I feel like the child either has pneumonia or doesn’t have pneumonia. If antibiotics are not indicated, why I feel like antibiotics are not indicated.
I recently saw a patient this week who actually had a diagnosis that was in the past and I didn’t feel like the child needed antibiotics now because they had already recovered from the illness. And I talk through of yes that back in the day that I feel like they could potentially have benefited from antibiotics, but since the child is doing great and back to baseline, I don’t think antibiotics are necessary at this time, and talking through them. Now, if the child develops symptoms again in the future, then I explain to the family maybe the child will need antibiotics again in the future, but we’ll have to take it step by step and day by day.
Dr. Gabi Hester: Lindsay, has your lens to this evolved in a different way because of your particular training in pediatric infectious diseases. How might you have a different lens perhaps if you were an outpatient clinician in a more general type of practice?
Dr. Lindsay Hatzenbuehler Cameron: I do think my lens would be different if I was an outpatient provider just because I would be seeing a different patient population. So those who come to me are either referred to me from the outpatient setting or they have continuity of care that came from the inpatient setting to my outpatient setting, or I see them on the inpatient setting because they have a presumed or confirmed infectious disease. So I do think my lens is a little bit different, but I also feel like as an expert in pediatric infectious diseases, I know the guidelines that the urgent care providers are using in the community.
And I recently had an online course for urgent care providers to actually enhance their communication with parents and also improve their knowledge on the management of upper respiratory tract infections. And I think not only did I have the ability to teach them about the guidelines in addition to being judicious about the use of antibiotics for the treatment of otitis media, pharyngitis and sinusitis, but also to enhance their communication with parents. So raise their awareness to the literature that’s out there that supports the usefulness of just being open with parents because often they may have a different perception of what the parents’ needs are in that encounter.
Dr. Gabi Hester: We talked a little bit earlier about just asking families what are you hoping for from this visit? One other question I have started using in my hospitalist practice is, what scares you the most? What are you most worried about that we maybe aren’t talking about? In your field, specific to pediatric infectious diseases, is that a question that helps families articulate some of their concerns?
Dr. Lindsay Hatzenbuehler Cameron: So I do think that that question is so valuable, especially if the child is either really sick or if the child’s been sick for a while. So I often use that question in those patients who I see with fever of unknown origin. So they come in for a prolonged or protracted illness and really no one knows what’s going on with them. And that I get through the entire history, the physical, I explain what I know so far.
And that in that time period, then I say, “Before I give you my thoughts, what are you most worried about so that I address that thought as well?” And to be honest with you, it’s usually not an infection, it’s usually cancer or something else that’s life threatening, that then I can talk them through like, “Okay, these are the reasons why I feel like it’s potentially not life threatening today, and that these are the steps that we’re going to take to try to figure out what’s going on, and that these are the things that support kind of against an oncologic process, and that if we need more investigative tests, that we could go through direction.”
So I think that provides a lot of reassurance. Often parents cry. And so making sure that you give them that time and allow them to cry and support them through that is very valuable as well for them. And then I always end the encounter asking, do you have any additional questions or is there anything that wasn’t clear? Another strategy that I’ve used is to try to summarize what I think is going on and what the next steps are going to be, and then they can rehearse that if that’s helpful for them.
Dr. Gabi Hester: I feel like in health care, especially as families and patients are in a period of great stress when they’re seeking care oftentimes, I feel like sometimes I walk into these conversations thinking I have a strategy and feeling like I have a good system for having that conversation, and then it just doesn’t go well. And as I reflect on that, I always wonder, what could I have done differently? And boy, that didn’t go how I planned. I thought of you, Lindsey, we know each other from our previous training and I’ve always thought of you as an expert communicator. Do you ever have conversations with families that don’t go the way you expected them to?
Dr. Lindsay Hatzenbuehler Cameron: In my practice, the hardest patients are those where I don’t feel like I have a good line of communication with either them or the parent, and that those are the ones that I struggle with the most. It’s either because there’s a lot of resistance in the acceptance of the diagnosis or there’s some harsh comments one way or another or harsh disagreements in a recommendation. And that I’ve learned over time to say, “Wow, this doesn’t seem to be going very smoothly. And so I’m going to have to say at this point we’re going to have to continue this conversation. I’m going to step back, and then I’ll leave.” And that there are times where I actually have to go to a clinical mentor to ask about their advice, to review the case with me.
And that I take that actually back to the parents saying like, “Hey, I reviewed this with my, for example, Dr. Kaplan, who’s my supervisor, and he totally agrees with what’s going on right now. And that we both agree that this is a really challenging situation, but at this point he wouldn’t do anything differently either.” And that having that conversation sometimes is helpful because they know that other people are thinking about their child. But I agree with you, having a challenging discussion or challenging conversations with families is never easy and that I don’t have the best strategy.
I kind of use them as a case by case basis. I have to know that I am vulnerable and that human as well. And so try to connect with them from both a sympathetic and an empathetic perspective. I can sympathize with them if I’ve been through it before, empathize with them because they have a very sick child and sometimes there’s uncertainty in medicine, and trying to explain that uncertainty and trying to connect with them so that we can build a relationship moving forward. And some families, it just doesn’t work.
Another strategy that I didn’t mention before is rescue scripts are really valuable. And actually the literature has supported that parents like having a backup plan so that if the child doesn’t improve as expected in the next 36 to 48 hours, that they could fill a prescription if needed. And the literature has actually supported that most prescriptions are never filled. And so just having that backup and that security blanket of having a prescription just in case the child doesn’t get better as expected that they could go and fill it.
Dr. Gabi Hester: That’s a great, great tip. So are there conditions where providers might more commonly use this rescue prescription strategy?
Dr. Lindsay Hatzenbuehler Cameron: The most common and the ones that I described in the urgent care course were for acute otitis media and sinusitis. So that there are guidelines to support the use of antibiotics in certain age groups regardless of their diagnosis of acute otitis media, but in older children, often it’s self limited in the sense that they’ll get better over time irrespective of antibiotics if they have a mild infection or mild signs of infection. And so that would be one strategy if there’s just a small amount of erythema and maybe a little bit of serous effusion that doesn’t look like it’s purulence, that you can watch and wait. And if the child fever don’t improve or the symptoms don’t improve, potentially that the child never needs antibiotics. That would be one that is a potential for using a purulence rescue script.
And then sinusitis I think is the hardest diagnosis to make actually because it’s based on clinical symptoms, right? And so that the guideline supports protracted symptoms greater than 10 days or a double sickening so that they actually have some initial illness that then gets worse again, or if they look unwell. So those who look unwell, it’s obvious like this child probably needs antibiotics. And that in the other ones, that there may be a timeframe where the child may clinically improve, especially if you can identify maybe a new viral illness that caused the change in clinical course.
Dr. Gabi Hester: That’s great. Lindsay, tell me a little bit about what might happen if we do overuse antibiotics, and thinking a little bit less on individual patient level and more on a global scale.
Dr. Lindsay Hatzenbuehler Cameron: We actually addressed the individual patient level factors, which would be an unwanted side effect which are often rash and diarrhea, and that they themselves could potentially then become resistant to that antibiotic over time, especially if they’re medically complex and have recurrent infections. But from my perspective as a pediatric infectious disease doctor, we are seeing more and more antibiotic resistant bacteria that we can’t treat with antibiotics that we used to be able to treat, so that some patients who were previously healthy are coming in with bacteria that we can’t treat orally. That’s crazy and also very scary in the sense of that our development of antibiotics is not keeping to pace with the antibiotic resistance the bacteria, unfortunately, are developing over time. So I think that’s the biggest concern is that antibiotic overuse is unfortunately leading to antibiotic resistance in the bacteria that we have in our communities.
Dr. Gabi Hester: So it seems really important that every provider, every health system comes up with strategies of how can I reduce unwarranted antibiotic use for the patients that I see, and how can I contribute to a system where we’re judicious about our use of antibiotics.
Dr. Lindsay Hatzenbuehler Cameron: And I think it comes from the top down in the sense from institutional bylaws in addition to antibiotic restrictions. It also takes educational interventions to educate the providers on the appropriate use of antibiotics in addition to communication courses, I think. I think we could do a lot more in teaching providers to communicate with parents, especially if they are antibiotics seeking, and to discuss the usefulness of antibiotics in that situation as well.
Dr. Gabi Hester: So Lindsay, I remember many clinic visits where you have a crying, ill child in front of you who’s wiggling and just not excited about you taking a really thorough look in their ear and doing the insufflation and all the other strategies that I know we’re supposed to do. How should a provider really approach those situations where you don’t really know if you can say with 100% certainty that they don’t have a bacterial infection?
Dr. Lindsay Hatzenbuehler Cameron: Super challenging. And maybe that child also has cerumen impaction, so you can’t actually see the ears. So I actually commend the pediatricians and providers in the community because they actually see these patients on a regular basis, and that there’s a lot of uncertainty. Could the child have started out with a viral illness? Now they have a bacterial component that would benefit from antibiotics. And that guidelines fit for most patients but not all. And so there is an amount of uncertainty that exists in the practice of medicine, right? And so, yeah, often giving antibiotics is a quick fix, but the question is whether or not it’s always necessary.
And so I think it’s important for pediatricians to be very systematic in how they’re going to evaluate the child. So insufflation is actually the best way to diagnose acute otitis media. And so making sure you just do that and you tell the family like, “Hey, I really need to look at the ears. I can’t see, so I’m going to actually get the wax out first and then I’m going to use my little insufflator to see if I can see the ear drum moving.” And like talking through with the family the steps on how you’re going to look at this child and the diagnostic steps that are necessary, which is not easy when there’s a crying child who has runny nose that’s like being flung all over you. It’s a very challenging situation, but I think it’s important to be systematic so that you can actually talk the family through a diagnosis or not a diagnosis.
Dr. Gabi Hester: Well, Lindsay, thank you so much for joining us today. Really appreciate your insights on how we can get to the heart of what families want and need in their visits with us. So thank you so much.
Dr. Lindsay Hatzenbuehler Cameron: Thank you so much for this opportunity.
Speaker: Take home points.
Dr. Gabi Hester: Number one, inappropriate antibiotic use may lead to antibiotic resistance, which is an emergent global problem. Number two, studies have shown that parents aren’t necessarily seeking specific antibiotics. However, what they are looking for is to trust in their providers. Number three, open communication strategies are key. Ask the family, what are you hoping for from this visit, or what worries you most? Number four, there are lots of available resources. Resources include evidence-based guidelines to help guide practice, parent educational materials, and communication courses that providers can use to boost some of their skills in having these challenging conversations.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Lexi Dingman is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.