American Urological Association (AUA) Panel
2006
Dr. David Diamond specializes in pediatric urology and robotic surgery. He is an Associate Professor of Urology at the Harvard Medical School. The second honored guest is Dr. John T. Boyle, who is Professor and Chief of Pediatric Gastroenterology at the University of Alabama at Birmingham.
Presentation depicts VCUG as “traumatic,” “distressful,” “dehumanizing,” and “like sexual abuse.”
“Once [VUR] is diagnosed, it has been the tradition that most pediatric urologists reassess patients annually. The issues involved with regard to follow up of the study of reflux are radiation exposure, repeated instrumentation of the child, which is a major issue for many families, antibiotic exposure, [and] cost.”
Q: “We as physicians interested in the urinary tract are severely criticized by many people for saying that we have really not asked the right questions…I want to know the outcome. I think we do too many cystograms and I want to know how the outcome of what you described versus not doing the cystogram […] I think the real issue is that within 5 years, we will not be doing cystograms [or] even ultrasonic cystograms, because I think catheterizing is invasive unless there is a real reason to do it. What is your feeling about this?”
Dr. Diamond: “This is an opinion that has been in the literature. The sense that I have […] it is exceedingly uncommon nowadays to see a patient present in renal failure due to [VUR]. My belief is that this is because we are probably doing something right. What does it cost? Is it worth it? Those are questions that I cannot answer…Undoubtedly, more studies are being done than absolutely need to be done.
“Our perspective is different from the radiologist’s perspective in terms of what your threshold should be for doing this study. It is largely because we as the tertiary consultants do not want to miss pathology…I think our feeling is that it is still important to err on being aggressive when the clinical indications are there, but at the end of the day, there are going to be many negative studies in children who were studied who would perhaps do just as well without it.”
Q: “The radiation-producing test that is not done reduces radiation 100%. I think that it is our job when we think a test is ordered inappropriately, and we may well be wrong, to call the physician up and talk to him about it. How do you as referring physicians feel about that?”
Dr. Diamond: “I have no problems. The problem is trying to get a hold of the physicians.
“Whenever I get a call from the radiologist, I will pull out the chart to see why I ordered that test. Sometimes there will be a little piece that was not communicated to the radiologist and he will say, ‘Fine, that makes sense.’ Sometimes he will say, ‘David, an ultrasound will do the job. What do you say we just send the kid over to ultrasound?’
“I always respect that call because it shows that they are doing a very thorough job. My perspective is that the practice of pediatric urology has changed. It has become a much busier enterprise. We are asked to see more patients in less time and sometimes these details slip through the cracks.”
Q: “In ordering a procedure, do you feel that it is your obligation to discuss with the parents what the procedure involves in terms of catheterization, potential pain, radiation exposure, etc., or do you then relegate that responsibility to the radiology personnel? Oftentimes, parents arrive and say, ‘What, a catheter?!’ or ‘What radiation?!’ and there has been absolutely no preparation for these families. What do you think should be the clinician’s responsibility for preparing the family for both procedures that can involve pain?”
Dr. Diamond: “I have never as a routine gone into the radiologic details because there are limited times in the day for me to see the patients that I need to see…Given the number of studies that we order throughout the day, there is not time to go over real issues with the parents. I think it is proper that someone do it, but it is not workable for us to do it.”
Dr. Boyle: “Our nurses do tell the parents that their child may be restrained.”