‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

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.

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

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).

http://www.seilevel.com/requirements/visual-models-save-live...

When the doctor saw me, she took my urine only and when it came back "perfect" she said I definitely did not have a kidney infection, that my pain was probably mechanical.

Two nights later and I couldn't move or think from the fever, the pain in my kidneys was so severe I could barely breathe, and I was fearing I was on the fast-track to sepsis (which I've had before).

Apparently the tech testing my urine sample fucked up, which is why the results came back perfect. The strange thing is, the doctor herself said she was surprised it was perfect, but took it at face value despite my insistence that I definitely had a kidney infection, especially considering I have a history of such infections. Also, when she said my pain was most likely "mechanical", I told her I hadn't done any intense activity lately, and she said I probably slept wrong, ignoring the fact I said I'd had a slight fever-- when they tested me at the hospital I had no fever.

It was a really weird experience. I understand skepticism against a patient's self-diagnosis, but I was claiming a kidney infection-- this is a common diagnosis for women with my symptoms and I've had many kidney infections before so I know what it feels like. Still, the doctor trusted that her three quick tests were perfect (urine sample, temperature, mechanical inspection) and her mis-diagnosis could have caused me permanent damage (kidney scarring or sepsis).