Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the Future?

Abstract

* Abbreviation: CAP — : community acquired pneumonia > It’s tough to make predictions, especially about the future. > > Yogi Berra In this issue of Pediatrics , Gao et al1 examine the value of clinical gestalt in predicting the progression to severe disease in children presenting to an urban pediatric emergency department with suspected community acquired pneumonia (CAP). CAP is one of the most common serious infections of childhood, accounting for ∼2 million annual ambulatory visits and 124 000 annual hospitalizations in the United States alone.2–5 Globally, childhood pneumonia accounts for significant morbidity and mortality, particularly in low- and middle-income countries.6 Complications of CAP include pleural effusions, empyema, sepsis, and others that may require additional procedures, ICU stays, and prolonged antibiotic courses. The management of CAP relies on appropriate diagnosis as well as thoughtful risk stratification to inform decisions, such as antimicrobial choice, patient disposition, and follow-up timing. Clinicians are often required to make these types of diagnoses and initial management decisions on the basis of brief encounters with patients. The impressions made on these visits often rely on a heuristic (ie, shortcut) approach to diagnosis and management. Much of medical decision-making relies on pattern recognition, which can include gestalt, gut feeling, or intuition.7 In this prospective cohort study, pediatric emergency medicine physicians were asked to estimate the probability that patients with suspected pneumonia (based on initial patient encounter and chest radiograph findings) will develop a complicated and/or severe pneumonia.1 The authors found that clinician gestalt was most sensitive (>90%) when the estimate for a complicated pneumonia was low and most specific (>90%) when the probability for complications to develop was judged to be … Address correspondence to Louis M. Bell, MD, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104. E-mail: belll{at}chop.edu