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Tuesday, July 8, 2014

Choosing a Physician For Babies and Children

I'm taking a break in the middle of my Learning and Behavior Series to answer a question that is often asked: How should parents choose a physician for their children?

photo source: Shutterstock


Most parents will spend a lot more time and effort in choosing a doctor for their children than they do picking a doctor for themselves. Finding the right fit is important. If you disagree with the doctor's treatments or don't feel comfortable asking questions, they aren't the right fit.

This blog will list a lot of questions to consider. It is mostly geared toward new parents, but if you have children already you should have an idea about what you liked and disliked about your child's last doctor. Use that knowledge to pick the new doctor. Unless you can book a three hour appointment with a doctor (I will say right now that no one really wants that), you will not get to all of these questions, so look ahead on their websites to see if you can find answers, then prioritize the questions that are important to you to ask first.

Pediatrician vs Family physician?


Family physicians and pediatricians both care for newborns. Some family physicians have quite a bit of experience with babies and children, others not so much.

I am of course biased toward pediatricians because they spend their entire three years of residency training after 4 years of medical school learning to take care of children birth through adolescence and transitioning into young adulthood. We continue to do continuing education in the area of children, giving us the opportunity to keep up on the newest recommendations. If you choose a pediatrician, ask how long they will see children. Most will see kids at least until 18 years of age. Many of us will see kids through college.

Family doctors learn to take care of people from birth until old age in that same three year period of residency, and much of their training is in the problems associated with getting old. Many do not keep up with the newest recommendations for children as research changes guidelines because there is so much information to keep up with adult medicine. If you choose a family physician, be sure they have experience with infants and young children.

References 


Ideally you will be able to ask friends, coworkers, and family members what they like and dislike about their pediatricians. Remember that everyone has different goals and experiences, so ask specific questions that might make a difference to you and remember that their view is colored by their experience. They might just say "the doctor's schedule is difficult to work with and they don't work with me" but they don't share that they had to reschedule an appointment because they were 30 min late and they were upset when they demanded that the doctor call out a prescription without being seen and the doctor refused. Or maybe they say that the doctor never does the right thing because they want "quick fixes" for all illnesses but the doctor uses standardized recommendations to avoid antibiotics for viral illnesses. Getting a variety of opinions helps to see if there's a trend toward that problem or if it's an isolated event.


Insurance


Unless you plan to go concierge, one of the first things you should do is look at the insurance of your future baby (or current children) to see which physicians are on the list. Compare the list of providers to the list of references you get from your friends and family. Don't forget to add your child to the insurance plan as soon as possible! There is usually a time limit of 30 days, and if you miss the opportunity, you will have to wait until the next open enrollment period. Mothers often assume the baby will be automatically added to her insurance, but if they don't get the paperwork and payment from you, baby is not added. Also watch your mail... insurance companies often will send a coordination of benefits that you must return to state whether or not baby is on another plan in addition to the one you signed up for. I suspect it is a delay tactic for paying claims, but  that is for another blog.


Prenatal visit 


Many physicians offer a prenatal visit. Some do individual one on one visits, others do a group visit so people can meet many faces at the same time. This is a time to get to know the practice style and bedside manner of the doctor. Don't limit your "interview" to just the doctor though... Look to see if the office is clean. Are the faces friendly? When you called to schedule was there a phone tree or did you talk to a live person? Are staff members helpful answering questions? I always recommend interviewing at least two offices so you can compare, even if your friends only have great things to say about one of the offices. You would never buy a house after just looking at one, right? See your options.


Hospital care


Once you limit the list of names down to a few that you can personally meet, see if they are on staff where you plan to deliver. Most hospitals require the baby's hospital doctor to examine him/her within 24 hours of birth, but their physician is usually not at the delivery. While it is not imperative that your child meets his pediatrician at the hospital (there will be plenty of time to get to know one another the first few months after birth), it is nice to know if you will need a different pediatrician in the hospital. If your chosen doctor is not on staff where you're delivering, you can ask if they recommend someone on staff at the hospital to "babysit" while you're there. I really think it is less important for a doctor to see your child in the hospital than many new parents perceive. They are often disappointed if a non-chosen doctor (even in the same group) is doing hospital rounds the days they are there, so they miss their chosen doctor. In reality, the hospital course is important, but with good communication between the hospital doctor and the long term doctor, good care will still happen. There is a lot of time later to get to know one another in the office setting. If you think about it, if your child's doctor spends too much time in the hospital doing rounds, he or she won't have as much time in the office to see your for visits for the next 18-22 years! Most newborns should be seen 1-2 days after discharge (unless they have been in the hospital longer than the typical 36 - 72 hours). Ask the doctors you interview when they usually see babies for the first visit in the office.


Office Availability and Policies and Physician's Practice Style


It is important that the office is accessible as much as possible. If it is far from home, work, and daycare, it will not be easy to run in when your child falls ill. The more hours they are open, the easier it will be to be able to go there for care, but the less likely you will see the same person each time. Things to consider (not all of these will be important to everyone, so think what your needs and goals are):
  • What are the hours for scheduled appointments?
  • Are there walk in hours, and if so what are they? Are they billed with an urgent care charge or a regular office visit?
  • What are after hour options if a child is sick or injured? 
  • Do they use a triage phone service or do they take their own calls? 
  • Are there charges for after hour services? 
  • Where do they recommend patients go after hours if needed? 
  • How long is the average wait time for an appointment for a sick visit? 
  • How long is the wait for a well visit (physical exam)? 
  • Do they charge for forms to be filled out and will they fill out forms outside of visits?
  • Do physicians outside of the office cover on weekends, vacation time, or after hours? If they do, how is that handled with billing and insurance? (Many solo or small group practices team up with trusted colleagues outside of their practice to help them all have a personal life. Yes. It's true. Even doctors like to see their families sometimes.) 
  • Is there a portal that allows secure electronic messaging for non-urgent questions?
  • Do they offer on line appointment requests or scheduling?
  • Do they offer on line bill pay?
  • Do they use electronic health records? If so, do they think it slows them down or has more benefits? Will you have access to the records?
  • Do they have an in-house billing staff or do they use a billing service?
  • How are medical questions during office hours handled? Is there a set time for phone calls to be returned or is it done throughout the day? Can you call and speak to a nurse? Do you have to schedule an appointment to talk to the doctor?
  • Is the location convenient to home, work, and/or daycare? Is parking convenient? If there are multiple locations, does your doctor have set hours at each location or at just one? Will you be expected to drive to various locations depending on day of the week or time of day?
  • If you choose a doctor in the practice, are you able to see other providers in the office if it is easier on your schedule or are you limited to just that doctor?
  • If they have physician extenders (nurse practitioners and physician assistants) will there be times that you must schedule with or use them? Can you choose an NP or PA instead of a doctor if you like their style best?
  • Are there other specialists in the office, such as nutritionists, psychologists, lactation nurses, etc?
  • What is the general schedule for well visits? 
  • Are immunizations available at the office?
  • Are labs and X-rays done at the office or at a location preferred by insurance?
  • Do they offer general advice on their website? Is it their own advice or do they purchase rights to use another database of information? If it's their own, is it updated regularly or out of date information?
  • Is there a separate waiting room for well and sick kids? I included this because it's on just about every list of questions to ask and I think it's a really bad question. I have admitted two kids in my 15 years in practice from their "well visit" -- both times the parents knew the kids were sick, but waited until the well appointment so they wouldn't have to come in twice in one week. Both kids had pneumonia and required oxygen and iv antibiotics in the hospital. Both would have sat in the "well" waiting room if we had it structured that way. In the winter most kids have a runny nose and cough at their well visits. Research shows that it is falsely reassuring to sit in the "well" waiting room for a scheduled physical, because kids come in for "well" visits sick or have siblings with runny noses that tag along. Some "sick" appointments are for injuries-- should they sit next to the kid with the vomiting bucket? I prefer that the waiting room is regularly cleaned and people don't spend much time there. Exam rooms can be cleaned before each family, and if families spend most of the wait in the room, it is less risky for catching something. I also think toys in a doctor's office are means to spread germs. Bring your own toys and books. And have everyone wash (or sanitize) hands when they leave.
  • Another question I usually see listed but don't like is "Do you run on time?" If they say "always" either they are 1. not popular, 2. brand new, or 3. lying. (I guess concierge docs can probably say always because they only see a few people per day.) Most doctors can run late at times -- it just takes one really sick patient, one parent with a lot of questions, or a room of behaviorally challenged children, to get a doctor behind. It happens. They can run on time 99% of the time, but if you're waiting with sick screaming kids, that doesn't help. What do they do to get back on track? Do they have other providers in the office help? Do they have "catch up time" built into the schedule? Do they shorten later visits to catch up? Do patients just wait? For more on waiting times, please see my previous post on Waiting Times.
  • How do they educate and update parents on new practice information or new pediatric recommendations? Do they have a social media presence? Do they send out newsletters? Does their website have a News section -- and is it updated regularly? If you're not online, do they offer paper copies of that same information? 
  • Are physicians board certified or board eligible? After residency new physicians must pass a standardized test to become board certified. Between the time they finish residency and pass the test they are considered board eligible. If they do not pass after 7 years (for pediatrics) they are no longer considered board eligible. They might just be bad test takers, but...
  • What is the physician's recommendation for common questions, such as breastfeeding, circumcision, car seats, use of antibiotics, starting solids, etc? Pick topics that mean something to you. If they are not on the same page as you with these, they will probably not be on the same page for other things.
  • How does the doctor keep up to date with current recommendations?
  • Do physicians admit sick children to a hospital or do they refer to hospital based physicians? Use of hospitalists is becoming more common throughout the country and in some markets is standard.
  • How does the doctor feel about specialist referrals? Some doctors like to handle a variety of issues, others are quick to refer before beginning a basic evaluation and treatments. Being able to stay in the medical home is great if the doctor is competent and comfortable managing issues. It is less expensive, comprehensive, and often more convenient for families. 
  • Do physicians in the office handle minor emergencies, such as laceration repair, broken bones, concussions, etc? How do they work that in to their schedule?
  • Are physicians able to manage most children with asthma? Can they monitor oxygen levels, do breathing treatments, check lung function, etc? 
  • What is the policy on calling out medications? 
  • Do the physicians in the office treat ADHD, depression, anxiety, and other mental health issues?
  • What is the physician's view on vaccines? Do they require them? 
  • Does the physician have an area of interest, such as infectious disease, endocrine, or behavior? 
  • If you have a special needs child, does the physician have experience with that disorder? I'm not saying they should be excluded if they don't. Are they willing to learn about the disorder and help you identify needs? I have a couple patients with different rare disorders I had never heard of before knowing them. They also see specialists locally and each have a guru specialist outside of the area that is nationally known for that disorder since there are few patients with the issue. The important thing is that I was willing to spend time learning about the issues associated with each disorder and how to help the families get the help they need.

I really think that the most important thing in a doctor/patient relationship is trust. If you feel uncomfortable talking to the doctor or if you disagree with what they say, it is hard to have trust. If you and the doctor are constantly butting heads about treatment plans, it is best to find someone more on the same page as you. If you know you want an antibiotic for every runny nose, but the doctor limits antibiotics to medically indicated instances, you will not be happy. If you do not plan on immunizing your child and the doctor's office requires vaccines, it obviously won't be a good situation. 

Remember that there are many choices in parenting. Most of the time you will make the right one, but if not you can usually change directions and find what works for your family. The same is true with the choice of a physician. Pick the one that seems like the best fit. If you are having problems, talk with the doctor. Often times this is best done as a phone call or letter so that a long discussion does not interrupt their patient schedule, making others wait. But is still important to share your concerns. He or she might not realize that the front staff was rude or that it took so long to get an appointment. They might presume you were happy with the treatment plan because you didn't ask questions or state your opinion. If you don't speak up, they will never know. Lack of communication is the root of most problems. If after discussing your concerns things don't change, then it is time to make a change to someone that makes a better fit.