On to out patient

I have now finished working in the inpatient unit, the nursery, the NICU. Tomorrow I start on the pediatric outpatient service. This entails working in a clinic near the hospital. I will see patients in the clinic from 7:00 am until 6:00 pm or so and I will also be responsible to round on any patients admitted into the hospital under my attending physician. If a community pediatrician has a patient of his / her show up to the hospital through the ER or a direct admit, the doctor has 24 hours to see the patient in the hospital and will then see the patient each day they are in the hospital. I am at a teaching hospital so the residents will also see these hospitalized patients like I did during my inpatient rotation.

Outpatient clinic is what most people think of when they think of their child's pediatrician. Most of the patients are in for ear infections, soar throats, abdominal pain, well child physicals and school physicals. Fortunately most of the patients seen in the clinic are fairly healthy and will not need to be hospitalized. The biggest role of the pediatrician in today's world is to determine the severity of the child's condition and make a diagnosis then reassure the parents that the child is ok. It is also a big challenge to try to convince the parents that antibiotics are not necessary in most instances. Many parents come in and demand antibiotics or feel cheated if their kid doesn't get antibiotics. Often parents will find a doctor that will give them antibiotics if their current doctor refuses. Most illnesses in kids are in fact viral and do not require antibiotics and on the contrary the antibiotics are dangerous for the child due to resistance build up. Furthermore even when the illness is caused by bacteria studies have shown that they will often heal without any antibiotics which explains why many kids who never see a doctor do not have chronic infections.

Most pediatricians complain about this antibiotic issue. It is a daily battle for them. There is a concern of the rare instances when a bacterial pharyngitis goes untreated and then later causes an auto immune response in the heart or the kidneys. This is very rare and also not completely proven to be caused by an untreated infection. The incidence is rare and when it does occur it is often in patients who have other autoimmune diseases and predisposed for these types of illnesses. Rheumatic fever has a similar mechanism. Also physicians do not want  to miss a meningitis. Liability also plays into the overuse of antibiotics. Doctors do not want to get sued and will practice defensive medicine and give antibiotics "just in case".  

Why is the overuse of antibiotics a bad thing? The problem is called resistance. Basically bacteria get exposed to antibiotics and have the ability to learn how the antibiotic works and then the bacteria mutates to avoid destruction by the antibiotic in future generations. If we can limit the exposure of antibiotics to bacteria we can hold off resistance. Given America's predilection to overprescribe many of our antibiotics have become ineffective. The resistance that everyone knows about is MRSA = Methicillin Resistant Staphyloccus Aureus. This pathogen is a direct result from overuse of antibiotics. 

In Europe they do not use antibiotics for Otitis Media (Ear infection) where we here in America give antibiotics like candy for Otitis Media whether they are needed or not. In Europe they have determined that the vast majority of ear infections resolve without antibiotics and they will hold off on using them until it is apparent that a child is not getting better on their own which is actually a very small %. In Europe they have less bacterial resistance.