The New York Times had a cover story recently reporting on the estimated prevalence of Attention-Deficit/Hyperactivity Disorder from the 2011-2012 National Survey of Children’s Health (they don’t identify the survey by name).
The story is going to get a lot of people interested in what is happening to children — every new datapoint on ADHD is noteworthy because it allows journalists to reopen the black box on childhood behavioral health disorders, and to raise the perennial alarm bells about over-diagnosis of children.
All of the issues raised in the article are valid. Many children with very mild impairments are getting a diagnosis, and enterprising drug companies are increasing demand for their product by implying that ADHD medications are a cure for generalized social impairments.
But — and this is critical – we have little systematic population-level data to compare the reported prevalence of a diagnosis with underlying data on ADHD symptoms in children. Continue reading “Inside the New Data on ADHD Diagnosis Rates”
Filed Under: Uncategorized
Tagged: ADHD, behavioral health disorders, Brendan Solaner, National Survey of Children's Health, overdiagnosis, Pediatrics, Studies
Apr 5, 2013
Q: “What is a well person?”
A: “A well person is a patient who has not been completely worked up.”
As I enter the exam room, a smiling 10-year-old boy greets me. Pete, my last patient of a long day, is here for his annual well visit. I chat with him about his life — home, school, nutrition, exercise, sleep, etc. — and I’m struck by something. Pete is really well. He’s well-fed (but not too much), active and well-rested, and, most importantly, he’s happy. He has not been to see me in an entire year, and only comes in for preventive health counseling. I think back on my entire day… and on my whole week. Pete is different from every other child I have seen this week. He is, in fact, the only truly “well” child I have seen in a long, long time. And I wonder — is he the last?
I’ve begun this post with a short riff on Dr. Clifton Meador’s satirical masterpiece, “The Last Well Person,” published in the New England Journal of Medicine in 1994. Meador profiles a 53-year-old man he imagines to be the last known truly “well” person in the U.S. in 1998. The patient is subjected to every known evaluation and found to be basically undiagnosable. I reflect on this story each day as I enter one examination room after another, visiting with patients (and their families) in my pediatric practice.
Sadly, the story of “Pete” is real. I no longer see many well kids even though I am a primary care pediatrician, dedicated to keeping kids healthy. Yes, I devote much of my time to counseling parents about lifestyle choices (e.g., nutrition, exercise, play, rest, sleep) to promote wellness and prevent disease. Still, each and every encounter must be “coded” with a numerical set of instructions based on diagnoses (associated with disease states) so that I can get reimbursed for the care I deliver. My ability to keep my office open (so that I can continue to try and help families keep their children healthy) is predicated on my skill in playing this diagnostic code game.
Continue reading “The Last Well Child”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: Clifton Meador, Diagnosis, Pediatrics, primary care
Nov 8, 2012
I have a split medical personality. On one hand, I am a pediatrician; I light up around babies and love to mess around with little kids. On the other hand, I am an Internist; I love complex problems and love talking to the elderly. But the one part of internal medicine which gives me perhaps the most joy is the opportunity to solve medical puzzles. Yes, pediatrics has puzzles in it too, but they are far more common in adults.
The term used for a medical puzzle-solver is diagnostician. It is always a great compliment to a physician to be called a great diagnostician. It means you are a good thinker, have a good store of facts, know how to organize your thoughts properly, and can see patterns in things you otherwise would never have found. It is the Sherlock Holmes, Lord Peter Whimsey, or Harry Dresden side of medicine. The diagnostician searches for clues, but especially searches where they are most often missed: right out in the open.
I am not sure anyone has called me a good diagnostician, but there are few things that give as much satisfaction in my job. It calls on my creativity, my memory, my mental organization, my ability to ask questions, my power of observation, and my ability to put all the disparate pieces together to form a cohesive whole. It’s not just coming up with an answer; it’s coming up with a plan. Continue reading “Your Doctor’s Brain”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: Diagnosis, diagnostician, New Doctor's Desk Reference, Pediatrics, primary care
Jul 12, 2012
Every day, there is another medical study in the news. There’s another newspaper or TV story telling us that X can cure depression or make you thinner or cause autism or whatever. And since it’s a medical study, we usually think that it’s true. Why wouldn’t it be?
But what most people don’t realize, let alone really think about, is that there might be other studies that show that X does none of those things — and that some of those studies might never have been published.
Just this week, the journal Pediatrics released an article that perfectly demonstrates this problem. There have been a number of studies that have shown that a certain type of medication, selective serotonin reuptake inhibitors (SSRIs), can help stop the repetitive behaviors of autism, like hand-flapping or head-banging. If you were to do a search of the medical literature, as doctors and parents and patients often do, you’d think that using SSRIs is a good idea. But when researchers dug deeper, they found that there were just as many unpublished studies that showed that SSRIs didn’t help. If they had all been published (they were all good enough to be published), that same search of the medical literature would have shown that using SSRIs isn’t a good idea.
This is bad. We rely on studies to guide our decisions. What is going on?
The journals that publish articles certainly play a role. After all, it’s cooler to publish a study that has a grabby headline, that promises an answer or a cure. That’s much more likely to get readers than a study that says that something doesn’t do anything at all. But it turns out that the researchers themselves play a bigger role.
Continue reading “Medical Research We Never Hear About: The Problem of Unpublished Studies”
Filed Under: Pharma
Tagged: ClinicalTrials.gov, medical literature, Medical studies, Pediatrics, published studies
May 2, 2012