A Pediatrician’s Dirty Little Secrets - Part 2
Robert P. Lindeman, MD, PhD
Natick Pediatrics, PC

This is the second in a series of articles that reveal what I refer to as ‘dirty little secrets’ about pediatrics in today’s world. The title is a joke, of course: there is neither anything dirty nor secret about the stories. I refer to them as secrets because if these stories circulated widely throughout the community and if enough parents believed the stories to be true, primary care pediatrics as we know it would vanish quickly. Most pediatricians don’t want to vanish quickly. That’s why these stories remain secret, until now that is.

Secret #2 – Most Ear Infections Do Not Need Antibiotics
The facts about middle ear infections are not in dispute. Approximately 80% of these infections go away without antibiotics. Studies show that when antibiotics are given for ear infections, the benefits are modest at best. If a doctor gave antibiotics to 8 children, a week later only one of them would have fewer symptoms than children with ear infections who weren’t given antibiotics. There is very little risk to holding off on antibiotics. Complications of middle ear infections, such as meningitis and mastoiditis (an infection of the bone surrounding the ear) are extremely low. These rare complications occur even when antibiotics are given.

On the other hand, there are real and significant risks associated with antibiotics, particularly when these drugs are not really needed. Antibiotics are notorious for causing nausea, vomiting and diarrhea. Significant numbers of children develop allergies to antibiotics as well. Finally, the bacteria are becoming resistant to the antibiotics we give to our children. There is evidence to suggest that antibiotic treatment promotes "super-infection" of children’s ears with resistant bacteria. Worst of all, we face the possibility of running out of antibiotics suitable for treating very serious bacterial infections.

Nevertheless, 5.2 million prescriptions for antibiotics are written for ear infections every year, when 4.1 million of these would go away quickly without a prescription. It is probably the case that nearly all would go away without a prescription in a week to 10 days. Why, then, are so many prescriptions being written? There are several answers.

The Doctor Wants to Stay in Business
As with any business, the pediatrics offices need to spend money in order to function. There are salaries and benefits, rent and condominium fees, and other overhead costs. Compared with other medical specialties, such as surgery, reimbursements for pediatrics are relatively small. Ear infections, or fears of ear infections, create an enormous amount of business for pediatricians. For many pediatrics offices in the U.S., "ears" pay the bills. It is probably not an overstatement to speculate that if society as a whole came to understand ear infections the same way enlightened doctors do, that many offices would have to go out of business.

The Doctor Wants to Feel Like She (or He) is Helping
Doctors in general tend to be nice people who are interested in helping other people. Pediatricians are no exception. When the pediatrician encounters a family with a sick child in the office, the pediatrician often feels as though the family should not leave empty handed. For a long time now, many pediatricians have felt that the only way to make the family feel good about coming to the office was to write a prescription. Otherwise, the family might feel that the doctor wasn’t helping them, or that she didn’t care about her patients. Many doctors fear that the families will seek care elsewhere if the doctor doesn’t write a prescription for an antibiotic.

The Pharmaceutical Industry is not Helping
Drug companies are in business for the same reasons doctors are in business: to help people and to make money, not necessarily in that order. Unlike most doctors, however, companies in the drug business need to market their product or risk losing customers. The latest trend in drug marketing is ‘Direct to Consumer’ (DTC) marketing. DTC marketing is gradually replacing one-on-one visits from ‘drug reps’ to doctors’ offices (the days of all-expenses-paid vacations are long gone). Anyone who has seen a Viagra spot on television or a banner on a web page is familiar with DTC drug marketing. Drug ads have appeared commonly in medical journals for a long time. Now such ads are appearing in parenting magazines. Antibiotic manufacturers hope that consumers, in this case, parents, will come to my office asking for particular antibiotics by name. And they do.

The ‘Medicalizing Effect’ of Going to the Doctor
If you bring your child to the doctor, and the doctor writes you a prescription for an antibiotic, it is natural to conclude that 1. You child needed to go to the doctor, and 2. Your child needed the antibiotic. The next time your child is sick, you will be more likely to call your doctor and ask for an appointment. The so-called ‘medicalizing effect’ of going to the doctor has been documented and validated in the medical literature. In fact, some studies demonstrate that the act of going to the doctor by itself generates more doctor visits, even if the family leaves without a prescription! Unfortunately, it is not necessarily true that the child really needed to go to the doctor to get a prescription. Even if there were a true bacterial ear infection, the overwhelming likelihood is that the infection would heal itself.

What Do We Do Now That the Secret Is Out?
This is good news for parents. If the secret gets out, and enough parents begin to believe it, they’ll begin to stop worrying that their child may need antibiotics every time he catches a cold or starts swatting at his ears. Parents will begin relaxing, watching and waiting, all the while giving their children the tender loving care the child really needs! Parents will call their doctors only when fevers last longer than four days, or if the child should suddenly become very ill-appearing.

What is good news for parents is bad news for pediatricians. If the secret gets out, pediatricians will have fewer "sick visits" in their offices. Fewer visits mean less revenue.

Of course, the truth is that pediatricians as well as parents want fewer sick visits from their patients. No one benefits from unnecessary use of medical services. Eventually, pediatricians will have more time to practice our expertise, tracking and monitoring growth and development, along with diagnosis and management of serious health problems affecting children.