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Learning and teaching
‘So why didn’t you think this baby was ill?’ Decision-making in acute paediatrics
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  • Published on: 18 January 2019
    Different guidance for a different time?
    • Damian T Roland, Honorary Associate Professor & Paediatric Emergency Medicine Consultant Leicester University and Hospitals

    Thanks Dr. Roussis, if I have read your comment correctly you express worry that guidelines, systems and protocols of the present were built on the combined wisdom of the past. That a new generation of doctors will use guidance as their clinical 'crux' and gestalt will become an increasingly less used (and perhaps required) commodity. This risks the loss of future knowledge that is encapsulated in the neuronal synapses of the experienced clinicians and can't be found within the electronic pages of a NICE pathway for example.

    If I am correct in your interpretation I agree this is a challenge. I would argue it is a challenge born of necessity in some respects though - the volume of information is much larger, the density of disease far different (a pre-test probability of meningococcal meningitis was much easier to calculate prior to the vaccine era ) and societal expectation more informed. This does not mean we should continue blindly forward. The application of combined wisdom has always been necessary (as you say perhaps "ubi pus, ibi evacua" was the first guideline) but I think we have lost our need to teach how to interpret this information taking into account the individual patient in front of us.

    Thank you for comments - debate in this area is certainly necessary and as stated in the article I personally believe social media has had a role, and will continue to do so, in driving this forward.

    Conflict of Interest:
    Author of original article.
  • Published on: 18 January 2019
    Can we reproduce clinical wisdom fast track

    Medicine has been practiced for thousands of years. Physicians (and surgeons perhaps) were armed with plenty of gut feeling and gestalt in order to practice effectively within their contemporary technical boundaries that should not be underestimated. The Latin aphorism "ubi pus, ibi evacua" is as valid today as always. As a mini flowchart it proved its value and effectiveness over time: incision and drainage of an abscess. However things were not always as simple. There have been a lot of arbitrary diagnostic and treatment modalities until not too long ago. Modern medicine with a trend towards evidence-based practice is a product of the second half of the 20th Century. Technology allowed the development of (patho) physiology and established knowledge of standard parameters of human body functions. This was a fairly straightforward process in the stability of the developed adult human body. It is however a significantly less solid process with the developing body of a child. The development and application of flowcharts cannot be as definitive as in adults even in a modern paediatric environment. Therefore it is true that one must rely on a larger average of developed clinical wisdom and sixth sense when making clinical decisions on sick children. It is also very true that clinical wisdom relates directly with one’s ability to reflect upon and learn from mistakes.
    The generation of doctors that will be retiring within the next ten years paved the way for a s...

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    Conflict of Interest:
    None declared.