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Two roads, fever, speculation and biases

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I attended a virtual presentation this week.

It was an old-fashioned clinical talk; the kind doctors have been doing for ages – essentially, someone stands in front of a group and talks their way through a case.

For me if felt refreshing to be beamed back into the hospital – I have been outside the system for almost eighteen months, hearing the old tropes about ordering ultrasounds and CT’s, interpreting blood results and so on has become removed from the community world I inhabit.

Central to the case was the theme of the clinical conundrum called ‘Fever of Unknown Origin’ (sometimes, Pyrexia or Unknown Origin) – FUO or PUO.

This is an unusual clinical scenario where mostly hospital doctors are faced with a patient who has a fever and they are unable, despite having access to all manner of sophisticated investigations and tests to find a diagnosis.

Mostly, when a patient has a fever, they have an infection.

Chest and urine are the two that are most often considered especially in older people; there is an entire gamut of other conditions which present with fevers that are either unusual infections such as tuberculosis, malaria or Lyme disease, through to other states that are a default complication of the inflammatory response – this is the way the body often responds when things going wrong, such as cancer or auto-immune disorders – for example, blood clots can cause a fever.

I won’t go into the details of this patient, although what was most striking for me was the cognitive bias were evident; essentially, although the clinical presentation and story described a fever, nothing else suggested an infection, yet, the doctors persisted in prescribing course after course of antibiotics with ever-increasing strength; (the trope being, if antibiotic A didn’t work, we need to try B which is stronger and then C and so on.) (This is how crazed battlefront generals operate as well).

The rheumatologists became involved and suggested using steroids (sometimes used for auto-immune conditions such as vasculitis), yet because of the spectre of ‘possible infection’ this was never taken seriously. (Steroids can made infections worse).

I think I counted five different antibiotic prescriptions – oral and intravenous.

Suffice it to say, in the end, the patient was found to have a rare blood cancer which did not respond to either antibiotics or any other form of treatment and he died.

Treating patients who have a fever even though you suspect they don’t have an infection with antibiotics represents a powerful cognitive heuristic.

Heuristics are the pathways or grooves laid down in our subconscious that make us behave in a certain way; habit. Something works this way, I will do it again, and again and so long as all things are equal, I am ok. If a variable changes and I don’t notice, I can be in trouble.

Our thoughts and behaviours, conditioned by social, cultural and professional norms accustom us to take the course of least resistance and often the path most commonly followed.

Indeed, it is not only easy to do what others might have done, it is safe.

If you undertake a treatment that is out of the ordinary and are proven wrong that is considered worse than following usual treatment and being wrong.

We don’t like to be considered daft.

We like to fit in.

It is a fact, in basketball, if you do a granny throw – that is through the ball with both hands from between your knees you have a higher chance of scoring, yet, no one does it – as if you do the granny and get the ball in the net, people accept your scored, but, if you miss, that is worse than the traditional over the shoulder throw. (See here for more information.)

In the past I have found myself in this position; possibly taking the unfashionable stance.

An older man who becomes more confused – everyone wants you to prescribe antibiotics for a urine infection; I resist, explaining there is no evidence for a urine or any other infection – people, particularly those who are frail, older and who have cognitive impairment can have ups and downs. A down does not necessitate antibiotics, just as being unhappy or under the weather does not require the prescription of an antidepressant; the medical heuristic says – depression = antidepressant; fever = antibiotic.

This lazy thinking has created entire industries.

It is becoming more difficult to resist professional norms.

Short-cut thinking is a powerful fashion.

Any ideas how to resist?

You might call this the human condition.

We are pack animals after all.

This is the secret of our success and sometimes our failure, when entire cultures take the wrong path or adopt the wrong norms.

The talk actually harks-back to a central theme of my blog; emotions and fear.

If you have a doctor or leader who is not restrained or constrained by fear, who is ready to listen, respond and act, sometimes go against the grain, that can make all the difference.

I’ll leave you with thoughts of Robert Frost.

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