On humility

Yesterday's Times Magazine has a harrowing article about shaken-baby syndrome. Its tragic and shocking subject matter makes it particularly challenging to read. I have (blessedly) never been directly involved in the care of a shaken infant. I remember a case being discussed at morning rounds once during my fellowship in New York City, but my subspecialty is unrelated and I heard nothing further about it. I hope I am lucky enough never to encounter this diagnosis again in the course of my career.

What I know about shaken-baby syndrome (on which I will not dwell in detail) is retained from residency, with a medical education conference or two on the subject since then. There is a constellation of findings that, viewed together, are pathognomonic for the syndrome. That is, if you find these things, they point conclusively toward shaken-baby syndrome. If these, then that, QED.

Except, maybe not?

A dozen years ago, the medical profession held that if the triad of subdural and retinal bleeding and brain swelling was present without a fracture or bruise that would indicate, for example, that a baby had accidently fallen, abuse must have occurred through shaking. In the past decade, that consensus has begun to come undone. In 2008, the Wisconsin Court of Appeals, after reviewing a shaken-baby case, wrote that there is “fierce disagreement” among doctors about the shaken-baby diagnosis, signaling “a shift in mainstream medical opinion.” In the same year, at the urging of the province’s chief forensic pathologist, the Ontario government began a review of 142 shaken-baby cases, because of “the scientific uncertainty that has come to characterize that diagnosis.” In Britain, after one mother’s shaken-baby conviction was overturned, Peter Goldsmith, then attorney general, reviewed 88 more cases. In 2006, he announced doubts about three of the convictions because they were based solely on the triad; in the other cases, Goldsmith said, there was additional evidence pointing to the defendant’s guilt.

I found this genuinely startling. There was such certainty in how I was taught regarding this diagnosis. If this, then that. If retinal hemorrhages and subdural hematomata are present, shaken-baby syndrome is the horrifying but clear diagnosis. Nothing left but to find the perpetrator. While this emerging information doesn't mean a baby with these findings wasn't shaken, it seems this diagnostic certainty is unfounded.

In my current position, I am not on staff in an emergency department. It is supremely unlikely that I will ever be called upon to make this diagnosis. The impact of this new controversy on my particular practice is likely to be minimal.

And yet, this was rather a dizzying article for me to read. It serves as an important reminder that, as a physician, there must always be humility in my approach to individual patients and accepted treatments. As a profession, we must always be willing to admit new information, and to question even the most seemingly unimpeachable evidence. It's good to be reminded of this now and then.

(As an addendum, this might lead regular readers to question if I would be willing to accept a link between vaccines and autism if evidence emerged to suggest it. My reply to this hypothetical question is that I have always been willing to accept a link between the two, were said evidence to meet the standards required of medical science. Given that the supposed link was first introduced through fraud [a fact his supporters are all too happy to blithely ignore] and no compelling science has actually supported a link despite vigorous and good-faith efforts to investigate it, I remain confident in my convictions. Should credible evidence emerge that causes me to question even this belief, I would give it my honest attention.)