Thursday, November 28, 2013

Holidays and family spoiled by illness... It's that time of year!

It is Thanksgiving morning as I write this. I am enjoying my quiet time as the family sleeps in. Extra time to blog because I'm not cooking today ... more on that later.
illness, flu, cold, cough, antibiotics, earache, ear infection, infections, flu vaccine
Wash hands to help prevent illness!

Yesterday was a typical day in our office for a day before a holiday. Sick kids came in with parents hoping for an insta-cure so they could enjoy the holiday with the extended family. A few wanted to fly back home with a febrile child and wanted our okay -- but of course didn't get it because even on an antibiotic they could spread illness if it is a virus, which most illnesses are. Some parents just called in because they were already out of town when their child got sick and they wanted to know what will make them better before the turkey celebration.

I'm sure most parents knew deep down that the answer would be "time". There is no insta-cure for most illnesses. Anyone with fever, cough, sore throat, or other ill symptoms should be kept away from the festivities. Even if the fever goes down with a fever reducer. Even if the last fever was before bed last night and it's down this morning. Fever can wax and wane and one needs to be fever-free (without a medication to bring it down) for 24 hours before we really consider it gone. People are most contagious when they are running a fever and the first few days of illness.

It stinks. I know. As a parent with a teen who has had a cough for over a week and is sleeping a disrupted 16-18 hours a day, I will miss Thanksgiving with extended family to avoid the spread of illness. Could we go? Sure. He hasn't run a fever all week. He's old enough that he can wash hands, cough into his elbow, and stay out of everyone's way. But he'd be miserable. And if one of the little ones got sick, I'd feel awful. Even if they got it elsewhere, I'd wonder if it was from him.

So I get it. It really stinks. Family from Tennessee and California are in town. We rarely see them and I want the cousins to get to know one another. But my teen isn't feeling well and I don't want the cousins to feel this way. I haven't started him on antibiotics to make him better faster because I know they wouldn't work. We are using a humidifier, lots of sleep, and waiting. He's refusing the nasal wash unfortunately... but I keep offering it!

This holiday season I wish everyone health, but if someone is sick, stay home. Don't spread the germs.

For more information on treating illnesses, see these links:

Cough and colds
Ear pain and infections
Wheezing in infants
Vomiting and diarrhea
Pink eye and other red eyes
Strep throat
Painful urination
Cough Medicines: Which One's Best?
Evolution of Illness

Tuesday, November 19, 2013

Urgent cares for routine illnesses ... yes or no?

photo source: Shutterstock
Every day I review reports from urgent cares that my patients visit outside our office. I know many parents go because they are worried about their sick child and want them to be seen immediately.

Some may not realize that our office has extended walk in hours ~ we are often open when they go to these urgent cares.

Or they might simply find it more convenient to go to the corner clinic near their house.

Other parents do not want to miss work (or let their kids miss school) so they go after hours to an urgent care clinic (despite our extended hours).

Sometimes there is a financial incentive for the family with a lesser copay at a walk in clinic because of the insurance contract with that company. (Don't get me started on the reasons that makes my blood boil...)

Urgent cares and emergency rooms are designed to quickly evaluate and treat patients with significant illnesses and injuries. They do not have the luxury of follow up, so they tend to err on caution and do more labs, x-rays, and prescriptions than primary care offices. This not only exposes kids to more medications, excess lab draws and x-ray radiation, but it costs parents more money. (Even if your plan doesn't require you to pay for that specific test, you pay for it through your premiums.) Although urgent cares cost less than emergency rooms, many are finding that costs are still well above those at a primary care office.

Most often visits are for things that could have been taken care of in the primary care office without all the added tests and treatments. A common visit to an urgent care is for ear pain. Often when kids are diagnosed with an ear infection, they leave the urgent care with a prescription for an antibiotic despite the fact that the large majority of these infections are caused by a virus and antibiotics are not effective against viruses. I suspect that part of the reason patients leave with a prescription and fill it right away is the urgent care wants to get patients in and out quickly. There's an ear infection and it's easier to just write a prescription for an antibiotic than it is to explain why it is okay to treat symptoms at home without a prescription for a few days first. They also don't have access to the past medical history and vaccine records, which can impact treatment choices, so they must be more cautious and treat.

And parents are happy. They "got something" for their visit.

Another common ER or urgent care visit is for fever or cough. At these visits they often get a chest x-ray and labs.

And parents are happy because "something was done" at the visit.

At the primary care office labs or x-rays might be done on occasion, but it is less typical. A good history of illness and physical exam usually can identify the most likely diagnosis. Instructions on how to manage the illness and when to follow up can be discussed.

And yes, this does cause less patient satisfaction sometimes because they didn't "get something" for their visit. What they got was an assessment, a diagnosis, a treatment plan of things to do at home to treat symptoms, and instructions on how to monitor for worsening of symptoms. Nothing tangible, but very worthwhile!

Unfortunately, many parents see excess testing and treatment as good care and don't realize that it is the inexperience of the provider who is over treating. An experienced pediatric-trained primary care provider would not need all this testing to be comfortable making a diagnosis and watching the patient over time without prescription treatments.

Even a provider with years of experience in an urgent care setting does not have the experience of watching a patient over time without interventions. They never get to see patients get better on their own. They never get that opportunity to learn from their patients. They learn in training to evaluate and treat, then send patients out the door (or in for admission). That's what they do.

A big issue I alluded to above is patient satisfaction. Urgent care and emergency room physicians and midlevel providers are often under pressure to make patients happy, which includes doing tests and giving prescriptions ~ after all, that's what the patient paid for, right? {sarcasm} 
My concern is that higher patient satisfaction scores are NOT associated with better care. Conversely, they have been associated with higher healthcare costs, increased prescription drug costs, and even higher mortality. (The Cost of SatisfactionA National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality)
 Even my patients who have seen me for years might be uncomfortable the first time they leave with a diagnosis of ear infection and are told to NOT use an antibiotic right away. I don't get blood work just because a child started with a fever today. My patient families know me. We've developed a trusted relationship, so they listen to my advice. They learn that it is okay to not do labs or start antibiotics because I take the time to explain what is going on, what is to be expected as things progress, and what to look for if the child's condition worsens. They know how to contact me or the on call provider if needed.

I know that Americans enjoy the convenience of walk in centers at every drugstore. I understand that there are situations when kids are so sick they need to be seen after hours. But I also encourage parents to consider if waiting until regular business hours is appropriate for whatever is causing their child to be sick. Never wait if it is a real emergency. But if your child can be managed safely at home with pain relievers, saline, humidifying the air, massage, rocking, or whatever fits the symptoms, please use your child's medical home when they open. There your child will be well cared for, records will be complete at the primary care office, and there will be less over testing and treatment.

I have blogged before about the benefits of going to your medical home  and when to see your PCP. I continue to stand behind the idea of patients going to their medical home for most visits because I feel you get better care and more personalized service, even if you see a different provider within the office. We have the ability to update your child's records, see past treatments, know your child's immunization status and have record of any allergies. We have the luxury of having you follow up so we know if things resolve or if further evaluation and treatment is needed. We don't need to order every test and treatment on the first visit, because most of the time they aren't needed. We might ask that you bring your child back in a short time to re-examine and see how the symptoms change. (For more on the value of repeated exams, see Evolution of Illness.) We will walk you through your child's illness if you come to us!

March 2014 Update: For an interesting read on how some doctors must overprescribe to get high rankings, see Patient Satisfaction is Overrated.

Saturday, November 16, 2013

Private discussions with the pediatrician

photo source: Shutterstock
Every once in awhile a parent will tell the nurse that they want the child out of the room to discuss an issue with with the doctor privately. This is usually something they perceive as a negative thing for the child to hear, such as the child being overweight or having behavior problems.

While I understand the parent's intentions, I find this to be disruptive and counter productive. As much as I try to find an excuse to have a child leave, it is usually obvious that the nurse keeps them out longer than needed.

If we have the child leave the room, he knows something is up. We are talking about him. But not sharing with him. What could possibly be so bad that we won't talk to him about it? (How do you feel when you suspect people are talking about you?)

Then there's the issue of any patient needs to know what the issue is so we can address it. My guess is most of these kids already know what the concerns are. They need help working on them. If they are overweight, we need to talk about what they eat, how they exercise, and how they sleep. If it's behavior problems, they need to give insight into how they feel and what leads to the behaviors. They need to be a part of the plan to fix the problems. If they aren't on board, they won't change their habits. I can talk about weight (or behavior, or drugs, or whatever the concern is) sensitively and in an age appropriate manner with the child. The kids at school are likely talking about it in a not-so-sensitive manner, so it's best to not make it worse by secretly discussing it.

If a parent really wants to let a physician know specific points without the child present, find a way to do that outside of a visit with the child.
Send in a letter or secure electronic message with your concerns before the appointment. Be sure it's at least a few days before the appointment so the doctor has a chance to review it!

Schedule a consult appointment for just parents to come in without the child.
Call in advance to tell the phone nurse your concerns so she can pass it on to the physician.

Don't bring siblings to an appointment where you want to discuss a private matter about another child.

All of these means allow the physician (or other provider) to know your concerns without blatantly kicking a child out to talk about something privately.

Saturday, November 9, 2013

Lip Licker's Dermatitis: AKA Chapped Lips

photo source: Wikipedia Commons
As the leaves fall and the wind blows, I know that I will start seeing kids with smiles bigger than life due to red swollen chapped lips. Parents frequently bring kids in year after year with this "recurrent rash" that comes every dry season and goes away (or at least improves) in the Spring.

Dry lips are a problem that tends to worsen with the treatment that comes most naturally: licking your lips. Saliva contains enzymes that break down food you eat -- or the lips you are licking. It also damages regular skin, so the skin around the lips dries if licked, the skin on the neck and chest are affected in droolers,  and thumbs or fingers can get really chapped if they are sucked this time of year. The same theories discussed below can be used to treat other dry skin worsened by saliva.

What can help?

First, stop licking your lips! I know that's easier said than done, especially for kids with a strong licking habit. If you catch them licking, offer a lip balm or suggest that they drink some water. Remember to praise them if they make a choice to do anything other than lick!

Adding humidity to the air helps and doesn't require child participation (since they resist so much of what we do). Even if you have a whole-home humidifier, add a vaporizer or humidifier to the bedrooms each night. Be sure to keep it clean and out of reach of little hands.

Everyone should drink plenty of water throughout the day.

Seal in moisture with a lip balm or ointment. Ingredients such as shea butter, lanolin, petrolatum, sunflower seed oil, squalane, and vitamin E are common. Products with glycerin, hyaluronic acid, or sodium PCA also have been shown to help. The more often they are applied, the better they work, so try to keep them available throughout the day. (This might require talking to teachers to allow it to be freely available at school.) Waxes are good to avoid dry lips, but don't help as much as a moisturizing product once the lips are already dry. Avoid products with eucalyptus, menthol, or camphor because they can increase dryness and irritation. Since flavored lip products might encourage licking lips, I suggest you avoid them. Use one with sunscreen when outdoors. Keep the balm handy throughout the day and be sure to apply after brushing teeth before bed. To avoid sharing germs, everyone should have his own, and I prefer sticks versus anything you dip your fingers into.  It is okay to apply the balm or ointment to the skin surrounding the lips if needed-- for those kids who have a wide area they lick around the lips!

Many parents ask if their kids will become addicted to the lip balm. Simple answer: No. They might use it more frequently as they get used to the idea of using it instead of licking their lips when they feel dry, but that is a good habit, not an addictive behavior. As soon as the weather warms up, we don't feel our lips being as dry, so we use the balm less often.

Avoid evaporation. Mouth breathing dries the lips, so try to get kids to breathe through their nose. Keep the wind off the lips with a scarf. The wind increases the evaporation of water from the skin, drying it out.