The renegade pediatrician

The Pediatric Insider

© 2012 Roy Benaroch, MD

Mark wants to know: “How often do you have a dissenting view of a recommendation by the AAP?  When a pediatrician doesn’t agree, are there any implications or difficulties for his practice?”

We’re talking about the AAP here—The American Academy of Pediatrics. I’m a “fellow”, as is just about every genuine pediatrician in the US. To give you an idea of what a bunch of tough-guy enforcers we are: at last year’s big AAP convention, the keynote speaker was Caroll Spinney. That’s right, Big Bird himself.  And if you don’t follow the AAP’s recommendations, he shows up and lays an egg on your head.

No, the AAP really doesn’t have any kind of enforcement. They don’t take your membership card away if you tick them off, or kick you out of the exclusive kiddie pool. Still, I think most practicing pediatricians probably follow at least most of their recommendations. Because, in fact, they’re our recommendations.

The AAP leadership is all pediatricians, from the national level to each state and local chapter. The “recommendations” endorsed by the AAP are written by pediatricians who are recognized as knowledgeable doctors and good, experienced thinkers. They work with specialty organizations, the CDC, and other big-brained types to come up with recommendations that really are based on solid science.

That’s not to say that I never disagree with their recommendations. For instance, until recently it was recommended that all young children get a study called a “VCUG” after even one urinary tract infection. However, good studies published after that recommendation showed that the VCUG may not be necessary, and may not even help; meanwhile, many of us became more concerned about the amount of radiation that we were using. No one wants to irradiate ‘lil ovaries unless it’s really necessary. The AAP’s recommendation, based on older studies, became outdated and flawed, and many of us practiced differently, counter to the recommendations, until it was updated.

I suppose one theoretical implication of practicing counter to recommendations is that you’d be more exposed in a malpractice lawsuit. But as long as what you’re doing meets the reasonable standard of care for your community, you’d probably be OK.

Most of the time, AAP recommendations make sense, and I follow them. They’re not a straightjacket, and they certainly don’t exhaustively address the peculiarities of every situation. I think if a pediatrician is going to practice counter to the recommendations, he or she ought to be able to explain why. As long as what we’re doing makes sense and is guided by the art and science of medicine, it’s all good.

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