Saturday, January 21, 2012

When To See Your PCP?

We have many kids who come in for what I consider "band aid" medicine. We only see them when they have a problem. They never come in when well so we can know more about them: what they enjoy doing, what good (and bad) habits they have, if they are growing properly... you get the idea.

I understand that it is time and money to visit the doctor's office, but it is time and money well spent.  Sometimes it isn't obvious that this is an investment that benefits in the long run, but preventative care has been shown to be worthwhile!  I typically feel that I give inferior care to kids I rarely see because I only see them when they are sick, and can only focus on the current problem, not the overall health. You can't use a band aid to fix a broken bone or high cholesterol.  Without proper evaluation, you don't even know you have some health problems.  Even our cars get better care: people do routine maintenance checks on their car every 3-5 thousand miles, they don't just call the service station when it won't start.

Many problems have few or no signs or symptoms until they become severe. Anemia, elevated lead levels, high blood pressure, growth problems, and behavior concerns are some that we typically only see when critical if kids don't come in for recommended visits or do recommended testing.  Some parents fail to bring kids to the lab or other facility for recommended evaluations. This can delay diagnosis and puts kids at risk.

There are kids who visit urgent cares often, yet never come in for routine care.  It may be years between visits with the primary care provider (PCP).  "PCP" is used broadly here, since the primary care isn't done.  I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.
I don't always trust an outsider's assessment of certain physical signs.  Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies.  Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction.  It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions.  It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...
I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed.  Bad habits can be reinforced because they simply have no way to learn better skills.
Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate.  Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting!  Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system!  It is okay to wait until office hours for many (if not most) problems. 
Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.
Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses.  Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications.  Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions.  Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.
Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum.  Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.
Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more.  These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage.  Examples of things recommended at various visits (depending on age):

  • height/weight measurements
  • blood pressure screenings
  • lab screenings (anemia, lead, cholesterol)
  • vision and hearing screenings
  • development assessments
  • mental health screens
  • more...    


I'd like to think that I can make a difference with healthy lifestyles by providing regular routine care. Sleep habits, screen time, exercise, safety, and more are discussed at various well visits. This might uncover issues that need additional visits to be properly addressed, but early recognition helps improve outcomes.

I know my own kids take what others at the office (other doctors, the midlevels, even the nurses) say about safety, nutrition, and sleep more seriously than when I say it. (Never mind that I have qualifications to discuss and advise on this topic, I am just Mom to my kids!)  I also recognize that I see my kids daily, but don't know their growth parameters, blood pressure, heart sounds, etc from day to day living.  I bring my own children in for routine well care and follow up of health issues so that they can be the healthiest they can be.  It has become routine for me to schedule their summer physicals every Spring Break.  This routine helps because:

  • it gives plenty of time to find a time/date that fits our busy family calendar and the provider's schedule. 
  • it is a routine, which helps me remember... yes, I forget to make appointments just like everyone else! (Others use birth dates to remember, but I prefer summer visits for many reasons.)



It is not uncommon to uncover a problem during a well visit that needs to be addressed more completely but wasn't recognized ... even by smart, educated, attentive parents.  Please join me in healthy parenting and schedule routine checks for your kids!  Do the tests, treatments, and follow up recommended by your provider or speak up during your visit if you don't plan on doing them, which allows for open discussion about why they should or should not be done.

Use band aides when appropriate, but treat overall health with routine visits!