Saturday, 27 June 2015

What was your question? (Easter egg - tests for bruising in children)

Fairly often, when a junior colleague is talking to me about a case I find myself asking, “What is your question?”  Sometimes the question comes at the end and sometimes not at all.  The thing is, I would prefer to have the question first and the details of the case second.  That helps me to understand everything that I am being told and it allows me to ask pertinent questions so that I can give useful advice.  I like it when people make things simple for me.

I realise however that this assumes that the person knows what their question is.  They might not.  Now this might seem like a bad thing but I have come to realise that it is not.  When someone comes to me without a clear idea of what is going on it means is that they have chosen me as a way of figuring out what their question is.  That is perfect.

What would be worse would be to do a test of some kind.  It might feel like this will add information, buy time, and clarify the question but it won’t.  If you don’t have a good idea of what the answer is before you do a test then you need to make sure that you know what your question is. 

Why is it particularly important to avoid unnecessary tests in paediatrics?  For two reasons:

  • Investigations in children should not be done lightly.  They have a tendency to cause anxiety, pain or involve radiation.  Children rarely consent to having investigations so we have an obligation to avoid tests unless they are really needed.
  • Most diagnoses in paediatrics can be made clinically and, if necessary, confirmed by an investigation.  It is unusual to use an investigation to look for a problem rather than to confirm it.  (The most significant exception to this is in testing urine in pre-school children.)
In most cases, one of two things is needed instead of tests:

  • A more detailed history and examination
  • Phone a friend
This brings me back to the discussions with my junior colleagues at work.  Discussing a case with a colleague is a superb way of clarifying your thoughts.  In many cases, the person who comes to me for advice has worked out what they want to in the process of discussing the case.  Sometimes I get phone calls from GPs who, half way through, decide they don’t need me any more.  If you work in primary or secondary care, this is the way to investigate a case, whether you know what your question is or not.

I was at the Trent Regional Paediatric Society yesterday and talking to Dr Suri from Rotherham who I know to be a very busy man.  Despite being so busy his genuine wish was that he was called more often for advice from his colleagues in primary care (and from the Emergency Department, I presume).  I realise that there is often little time to deal with a hospital switchboard but I would say that it should take less time than filling out a form for a test and later working out what to do with the result.

A good example of this effect of tests bringing more uncertainty is the child with bruises.  If you do a clotting screen I bet you will get one of the many results reported as being just outside the normal range.  Is that significant?  I don’t know.  What was the question?  If the question was “does this child have Haemophilia?” then the tests for that are complex and usually only done by a haematologist.  If the question was “can I rule out a clotting problem?” then even a normal clotting screen doesn't fully do that.

What is more likely to answer the question is a history that includes family history of bleeding disorders, excessive bleeding such as during dental procedures and cuts that never stopped bleeding.  An examination looking for lymphadenopathy, hepatosplenomegaly, joint problems, bruises in unusual places and petechiae anywhere is indicated.  In most cases I will not need to go ahead and do any test.  If I do want a test I might get a full blood count.  In that case I know what my question is: does this patient have thrombocytopaenia (e.g. ITP)?  A clotting screen will not answer that question so I don’t add it on just because I am taking blood.   The bottom line is that a clotting screen is not a good way to rule in or rule out clotting disorders in well children.  If in doubt I phone a friend.

What is certainly true is that a test might confuse the situation but discussing the case with someone who wants to help never should, assuming that they are experienced and helpful.  So, if you find yourself wanting the answer to a question or even unsure what your question is, phone a friend.  That could be a colleague where you work.  Alternatively, and if you can get hold of us easily, I hope that you will find your consultant colleagues in secondary care better value than the test you were wondering if you should do.   Another clinician willing to discuss the case is so much better than a test.  Why?  Well you can question a colleague; you can get their experience in addition to your own; they will bring new perspectives.  You can even disagree with them.  I tried arguing with a test result once.  It didn't work.

What I have learned from all this is to stop asking my colleagues at work, “What is your question?” and instead to enquire if the person has a question.  If not, that’s great.  Now I know that we are figuring out what the question is together.

Edward Snelson

Disclaimer:  I may occasionally forget all this and ask you what your question is.  I am probably tired.  Please make allowances.

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