5 ms·

The doctor rings true. I had 3 separate doctors on 3 separate occasions diagnose my 21 month old son with an ear infection, instead of the plum-sized malignant

by pards 5y ago

The doctor rings true. I had 3 separate doctors on 3 separate occasions diagnose my 21 month old son with an ear infection, instead of the plum-sized malignant brain tumour that it was. From their point of view, pediatric brain tumours are very rare and ear infections are common. Their 99% heuristic almost killed him. That was 2010. He survived and is now a vibrant 13 year old, but only because of one curious intern/fellow at the children's hospital ER that decided to order a CT to rule out the remote possibility. Her diligence got him admitted and into surgery within a day.

SomewhatLikely 5y ago
As in the examples in the article, it's those early in their career who are less likely to be following the heuristic.
s1artibartfast 5y ago
That is amazing, and congratulations! Do you mind sharing some more info on the cancer type? I thought most malignant brain tumors didn't have outcomes like this.
jozvolskyef 5y ago
It is a tough call this one. If my calculations are correct, based on data from[1], male infant head CT scans cause one excess death per ~3k scans. There must have been something else than a remote possibility to warrant ordering it. [1]: https://www.ajronline.org/doi/full/10.2214/AJR.12.10294 https://www.ajronline.org/doi/full/10.2214/AJR.12.10294
- Jupe 5y ago
  I interpret the linked article different. Can you elaborate? For example (from the summary): =============================== "CONCLUSION. Radiation exposure from the use of CT in the evaluation and management of severe traumatic brain injury causes negligible increases in lifetime attributable risk of cancer and cancer-related mortality. Treating physicians should not allow the concern for future risk of radiation-induced cancer to influence decisions regarding radiographic evaluation in the acute treatment of traumatic brain injury." (edited: formatting)
  - jozvolskyef 5y ago
    Excess Cancer Mortality per 100,000 individuals exposed to 100mSv is ~1000 in the 1 year-old male cohort. A single scan is ~3mSv, which makes the mortality ~30 per 100k, or 1 in ~3333, assuming the linear no-threshold model[1]. When someone comes to the ER with a traumatic brain injury, a CT scan is the standard practice because they are at a high risk of dying and presumably the scan is important for reducing the risk. [1]: https://en.wikipedia.org/wiki/Linear_no-threshold_model https://en.wikipedia.org/wiki/Linear_no-threshold_model
    - mercutio2 5y ago
      I'm so glad you mentioned the linear no-threshold model. Do you believe in it? I don't, particularly at the single digit mSv level.
      - jozvolskyef 5y ago
        At some point there will be enough data from different countries to confidently support or reject it. Until then I see it as the preferred hypothesis by Occam's razor and also because I'd rather err on the side of caution.
  - gilbetron 5y ago
    You need to read those things literally. It doesn't mean CT scans should be used whenever a doctor thinks. It means that a doctor evaluating a TBI should be ok with using it. Basically, the odds switch when there is an additional symptom that there is something wrong with the head.
- nemonemo 5y ago
  Maybe being an ER doctor itself could bias their decisions more favorable toward CT scans. ER people may see dead people & people with tumors more often than pediatric doctors in their offices. The usual pediatric doctors would see much more patients with ear infections. Also, to ER people, knowing the root cause is probably important for patients' survival, whereas for pediatric doctors, more often than not, lives are not at stake and customer service/easing parents' fear is more important.
ramoz 5y ago
Thanks for sharing, and hope all is well now. This also rung true for me, and is rather scary/disappointing. I have a rule now, after experiencing cancer & failed remissions with a family member, which is to always do the deep check. Esp in any case of pain or discomfort that isn't normal. Even a recent shoulder tear from lifting, the pain/discomfort wasn't something I had experienced before, so I went to a local ER (was worried about a dislocated shoulder). The young physician tried to usher me out with his confidence it was a normal injury most likely (he was right). I asked why not just do an x-ray and he gave me a response based on his heuristics. But the x-ray was an option if I wanted. So we did the x-ray and 20min later he was right.
PragmaticPulp 5y ago
> The doctor rings true. I had 3 separate doctors on 3 separate occasions diagnose my 21 month old son with an ear infection, instead of the plum-sized malignant brain tumour that it was. This one is difficult. The first doctor with the first diagnosis was likely doing the right thing. Although tragic, it's exceedingly rare for someone that young to present with a brain tumour. If a doctor was ordering CT scans every time someone arrived with ear infection symptoms, they statistically be causing more harm than good. CT scans raise an individuals risk of cancer ever so slightly. Not a big deal for individuals, but scaled up to an entire population it's actually a real creator of cancer risk. Now obviously if you have some serious symptoms then the incremental risk of a CT scan is less than the risk of missing a serious diagnosis. However, jumping straight to the CT scan without good reason would be a mistake. So now doctors are in a position where they must integrate diagnostic history into the equation. Showing up to multiple doctors with an "ear infection" that isn't responding to any treatments warrants deeper investigation. If the issue isn't resolved, proceeding to imaging makes sense. This is why it's important to begin return visits with a summary of what's been done so far. If you get a doctor who wants to re-start the diagnostic process without accounting for previous work done so far, unfortunately the only real solution is to move on to someone else.
- kirrent 5y ago
  Exactly, the post is a Scott Alexander post so he'd never object to the concept of priors. There's nothing wrong with having a strong prior that the volcano's not going to blow up this year, that it's just the wind not a break-in, or that it's most likely an ear infection with a tumour so unlikely as to not be worth the radiation risk and cost of a CT. Really, the article is about people who don't bother to monitor the likelihood that updates their prior because the prior is so damn explanatory anyway. But, a doctor treating an ear infection isn't doing this because the act of treatment is also a test. It's not the 'did the volcano erupt' or 'did we get burgled' test with huge downsides because even if there's a serious underlying issue a week or two is unlikely to change too much. If the purported infection doesn't clear up then it's time for the doctor to update their prior and reconsider what investigations or treatment options are now appropriate. Even better than taking your history to your next doctor, keep seeing the same doctor.
blue11 5y ago
I'm very glad to hear that your son had a happy outcome! "Ear infection" is often not even a heuristic. Pediatricians sometimes say that when it's not obvious what's wrong with a small child that has a little a bit of fever and is crying. Parents need to hear a reason and "ear infection" sounds more convincing than "probably nothing", and sometimes parents can be, well, difficult. I've even heard a pediatrician admit as much once. On another occasion, a nurse practitioner diagnosed our child with an ear infection without even bothering to check the ears. Emergency physicians, on the other hand, are always thinking about the worst case scenarios and trying to rule them out.
gilbetron 5y ago
Running a CT scan on every kid suffering from ear pain is a bad idea, not only economically, but from the negative effects of radiation exposure to so many kids. I know in your head the scenario was "were it not for that one person, my kid would've died", but the more likely scenario was, "the symptoms got worse and then a doctor decided it was enough to warrant another look and the tumor was detected, surgery was performed, and my son was ok". It was wonderful that it was caught when it was, but odds are very high your son would've still been ok even if it had been caught over the next several weeks. Also, I'm very relieved to hear your son is ok, as a father of a 13 year old son, you lived through a nightmare!

by pards 5y ago

SomewhatLikely 5y ago

As in the examples in the article, it's those early in their career who are less likely to be following the heuristic.

s1artibartfast 5y ago

That is amazing, and congratulations! Do you mind sharing some more info on the cancer type? I thought most malignant brain tumors didn't have outcomes like this.

jozvolskyef 5y ago

It is a tough call this one. If my calculations are correct, based on data from[1], male infant head CT scans cause one excess death per ~3k scans. There must have been something else than a remote possibility to warrant ordering it. [1]: https://www.ajronline.org/doi/full/10.2214/AJR.12.10294 https://www.ajronline.org/doi/full/10.2214/AJR.12.10294

Jupe 5y ago
I interpret the linked article different. Can you elaborate? For example (from the summary): =============================== "CONCLUSION. Radiation exposure from the use of CT in the evaluation and management of severe traumatic brain injury causes negligible increases in lifetime attributable risk of cancer and cancer-related mortality. Treating physicians should not allow the concern for future risk of radiation-induced cancer to influence decisions regarding radiographic evaluation in the acute treatment of traumatic brain injury." (edited: formatting)
- jozvolskyef 5y ago
  Excess Cancer Mortality per 100,000 individuals exposed to 100mSv is ~1000 in the 1 year-old male cohort. A single scan is ~3mSv, which makes the mortality ~30 per 100k, or 1 in ~3333, assuming the linear no-threshold model[1]. When someone comes to the ER with a traumatic brain injury, a CT scan is the standard practice because they are at a high risk of dying and presumably the scan is important for reducing the risk. [1]: https://en.wikipedia.org/wiki/Linear_no-threshold_model https://en.wikipedia.org/wiki/Linear_no-threshold_model
  - mercutio2 5y ago
    I'm so glad you mentioned the linear no-threshold model. Do you believe in it? I don't, particularly at the single digit mSv level.
    - jozvolskyef 5y ago
      At some point there will be enough data from different countries to confidently support or reject it. Until then I see it as the preferred hypothesis by Occam's razor and also because I'd rather err on the side of caution.
- gilbetron 5y ago
  You need to read those things literally. It doesn't mean CT scans should be used whenever a doctor thinks. It means that a doctor evaluating a TBI should be ok with using it. Basically, the odds switch when there is an additional symptom that there is something wrong with the head.
nemonemo 5y ago
Maybe being an ER doctor itself could bias their decisions more favorable toward CT scans. ER people may see dead people & people with tumors more often than pediatric doctors in their offices. The usual pediatric doctors would see much more patients with ear infections. Also, to ER people, knowing the root cause is probably important for patients' survival, whereas for pediatric doctors, more often than not, lives are not at stake and customer service/easing parents' fear is more important.

ramoz 5y ago

Thanks for sharing, and hope all is well now. This also rung true for me, and is rather scary/disappointing. I have a rule now, after experiencing cancer & failed remissions with a family member, which is to always do the deep check. Esp in any case of pain or discomfort that isn't normal. Even a recent shoulder tear from lifting, the pain/discomfort wasn't something I had experienced before, so I went to a local ER (was worried about a dislocated shoulder). The young physician tried to usher me out with his confidence it was a normal injury most likely (he was right). I asked why not just do an x-ray and he gave me a response based on his heuristics. But the x-ray was an option if I wanted. So we did the x-ray and 20min later he was right.

PragmaticPulp 5y ago

> The doctor rings true. I had 3 separate doctors on 3 separate occasions diagnose my 21 month old son with an ear infection, instead of the plum-sized malignant brain tumour that it was. This one is difficult. The first doctor with the first diagnosis was likely doing the right thing. Although tragic, it's exceedingly rare for someone that young to present with a brain tumour. If a doctor was ordering CT scans every time someone arrived with ear infection symptoms, they statistically be causing more harm than good. CT scans raise an individuals risk of cancer ever so slightly. Not a big deal for individuals, but scaled up to an entire population it's actually a real creator of cancer risk. Now obviously if you have some serious symptoms then the incremental risk of a CT scan is less than the risk of missing a serious diagnosis. However, jumping straight to the CT scan without good reason would be a mistake. So now doctors are in a position where they must integrate diagnostic history into the equation. Showing up to multiple doctors with an "ear infection" that isn't responding to any treatments warrants deeper investigation. If the issue isn't resolved, proceeding to imaging makes sense. This is why it's important to begin return visits with a summary of what's been done so far. If you get a doctor who wants to re-start the diagnostic process without accounting for previous work done so far, unfortunately the only real solution is to move on to someone else.

kirrent 5y ago
Exactly, the post is a Scott Alexander post so he'd never object to the concept of priors. There's nothing wrong with having a strong prior that the volcano's not going to blow up this year, that it's just the wind not a break-in, or that it's most likely an ear infection with a tumour so unlikely as to not be worth the radiation risk and cost of a CT. Really, the article is about people who don't bother to monitor the likelihood that updates their prior because the prior is so damn explanatory anyway. But, a doctor treating an ear infection isn't doing this because the act of treatment is also a test. It's not the 'did the volcano erupt' or 'did we get burgled' test with huge downsides because even if there's a serious underlying issue a week or two is unlikely to change too much. If the purported infection doesn't clear up then it's time for the doctor to update their prior and reconsider what investigations or treatment options are now appropriate. Even better than taking your history to your next doctor, keep seeing the same doctor.

blue11 5y ago

I'm very glad to hear that your son had a happy outcome! "Ear infection" is often not even a heuristic. Pediatricians sometimes say that when it's not obvious what's wrong with a small child that has a little a bit of fever and is crying. Parents need to hear a reason and "ear infection" sounds more convincing than "probably nothing", and sometimes parents can be, well, difficult. I've even heard a pediatrician admit as much once. On another occasion, a nurse practitioner diagnosed our child with an ear infection without even bothering to check the ears. Emergency physicians, on the other hand, are always thinking about the worst case scenarios and trying to rule them out.

gilbetron 5y ago

Running a CT scan on every kid suffering from ear pain is a bad idea, not only economically, but from the negative effects of radiation exposure to so many kids. I know in your head the scenario was "were it not for that one person, my kid would've died", but the more likely scenario was, "the symptoms got worse and then a doctor decided it was enough to warrant another look and the tumor was detected, surgery was performed, and my son was ok". It was wonderful that it was caught when it was, but odds are very high your son would've still been ok even if it had been caught over the next several weeks. Also, I'm very relieved to hear your son is ok, as a father of a 13 year old son, you lived through a nightmare!