and why protocols are not the answer to good diagnosis and risk management.
Excellent BMJ editorial telling it like it is.
“identifying those febrile young children with the greatest risk for serious infection at the time of clinical presentation is like looking for a needle in a haystack.” Essentially, if you have a child with a fever, there are no great lab tests that will tell you if the child is seriously ill or has a fever from a virus which will sort itself out.
Bayesian reasoning is, I think, the better answer. Some people call it ‘gut feeling‘, but I think this experienced, multi-layered medical response is less voodoo and more a mixture of all kinds of things: knowledge of the family, the previous interactions with the child, how the child looks, responds, what findings there are on examination, progress over time – not just the presence of a fever. Bayesian reasoning is a much more fluid process: you get new information (pink eardrum, two odd-looking spots) and you change the direction of thinking because of it; you do not stick to a linear protocol if you are on the wrong one.
This is important because cheaper medical care tends to be based on less qualified staff following more protocols. If you get onto the wrong protocol, you might not be able to backtrack and get onto the right one. With no lab tests to rely on, identifying a sick child should be done by staff who don’t just use protocols, but deep knowledge.