Paediatrics is a specialty where lying about a diagnosis is normal practice. It's not because we're bad people. When you think about the challenges of diagnosis in children combined with the expectation of a diagnosis, it is completely unsurprising. The adult accompanying the child would like a diagnosis (please and thank you) and the clinician would very much like to give one (you're welcome).
While that all seems very reasonable, in child health it often isn't entirely truthful. It is one of the mantras of medicine that the diagnosis is going to come from history and examination in most cases. Hurrah for clinical diagnoses. In paediatrics, the history is often from a third party and will have an inevitable element of bias. The examination will also contain more uncertainties more of the time. You have to accept a significant lack of information when interpreting examination finding in children.
The result of this is that clinical diagnosis is more challenging in paediatrics. Here's the paradox: clinical diagnosis is the default position in child health. Why? Because we don't want to do tests on children or give them treatments "in case" unless these investigations or therapies are very likely to benefit the child.
This week, something big happened and it didn't even hit the news. The General Medical Council released some new and updated guidance: "Guidance on professional standards and ethics for doctors Decision making and consent." While much of the content is old news, there is a new emphasis on honesty when there is diagnostic uncertainty that is hugely relevant to paediatric practice, thanks to the fact that uncertainty is where we work.
So, when are we lying to our patients or the adults that accompany them? The truth is that there is a spectrum of how far what we tell people lies from the truth. What we should probably do in the light of the new GMC guidance is to re-evaluate our approach to a variety of clinical presentations and ask, "Should I change what I say about this?"
You could argue that nothing is certain in medicine, so what are the thresholds of uncertainty that decide when we should be honest in this way? That's a fair comment. We need to apply some measure here - enter the certometer.
- Febrile convulsion
- Vasovagal syncope
- Infant reflux disease
- Cow's milk protein allergy (non-IgE)
- in the under 5 yr old child
- where the diagnosis is based on chronic cough without wheeze
- Mesenteric Adenitis
- Growing pains
- Non-specific abdominal pain
Disclaimer: I am not certain about any of that, or that you or I exist.