Summertime = School Physical Time!

Summertime is the time many school aged kids get their annual check ups. In Kansas it is important that high school aged kids do their physicals after May 1st if they want to participate in a school sport. Other kids simply don't need to miss school on their birthday to do a physical. It's also good to avoid our office during sick season if possible. For all these reasons, summer time is a great time to have a well check. So if you haven't scheduled your physical exam yet, it's time to call! Appointments do fill in fast.

Why do healthy kids need to come in? It's recommended that kids have annual screenings for growth, development, injury prevention, and more. Actually there's so much that we are supposed to discuss and do at a well visit that it is impossible to do it all in a standard 20 minute exam. (See Drowning in a Sea of Advice for more.)

To help with this enormous volume of information, we use handouts and our website to share a lot so we can spend time at the visit discussing your other questions. Please take the time to register each of your children on our website so you will get a pre-visit e-mail. This is becoming even more important as we are trying to be your true medical home and provide the best care to every patient with their unique needs.

To register, simply go to www.pediatricpartnerskc.com and click on the "Create an Account" tab at the top of the page and fill in the information. (Note: Firefox seems to be the best browser for our website. If you are using Explorer or Safari and cannot get the site to load properly, try Firefox.)

Once you've registered the first child, it's easy to add family members. See our How To page for details!

By registering each child you will be able to not only receive these informational pre-visit e-mails, but also ask questions to our front office staff or your favorite providers in a confidential password-protected manner, and pay bills online. Everything is confidential and we will never sell your personal information. 

Our pre visit e-mails have age-specific information to consider before your visit. Please take the time to read through it. Each e-mail has a homework section that is especially important. If you do your homework before the visit, you will find the visit to run more smoothly and you will get more out of it.

This summer I am doing a test of sorts. We are including several printables on the pre-visit e-mail to make your office time easier. You can print your patient information sheet if needed (due once/year, usually at the annual checkup, so young children who come more often don't always need these). We are starting a pre-visit questionnaire that will help identify any concerns to address at the visit. I am hopeful that we will be able to cover more of your specific questions if we know you have read the information on the e-mail, so we don't have to repeat all of the standard things. This should allow much better use of time at your visit to address your concerns.

Watch for your pre-visit email and take the time to read it! I hope to see your kids for their well checks soon!

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.

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.

 

Waiting times...

No one likes to wait at the doctor's office.

We don't want patients to have to wait.

We want to get home to our families at a decent hour each day.

Thankfully our waiting room doesn't usually fill up as above. (This is a screen shot from our Harlem Shake video.) Since our move to our new location, we have fewer people showing up late ~ amazing what a convenient and open parking lot can do ~ and this has contributed to our being on time more often.

Unfortunately there are always things that can come up unexpectedly in our schedules. We can be running right on time, but one patient is all it takes to fall behind. Please be patient! Remember that if it is your child that needs the extra time, we will take that time. We do respect your time and know that it is important, so our office will also accommodate patients as needed. If one provider is running behind, another will offer to see your child if that will help everyone be seen more quickly.

If it is important to you to have less of a wait time, avoid late morning or late afternoon appointments (more time for us to get caught up in something), and avoid busy Mondays and Fridays, as well as the day before and after holidays.

What makes the wait so long in the first place and what do we do to prevent long waits?

• Sick kids. Most of our “sick” appointments are fairly quick visits, and are scheduled as such. Children who are truly sick and require more time (breathing treatments, stitches, admission to the hospital, sending for x-ray, or watching as they sip fluids over a few hours) back us up. They take extra provider and nursing time and may tie up a room for several hours, limiting the available rooms for other patients. Please understand that this may happen any time, and even an otherwise low patient volume day can be consumed by one sick child. Most importantly, if it is your child, we will spend the required time to adequately treat him/her. If one provider is backed up, we will attempt to have another provider help out.

• “Oh, by the way…” This is a common phrase in any doctor’s office. When you have an appointment for one thing, but bring several concerns, the visit runs long. Scheduling experts recommend putting off all non-urgent and non-related things for future appointments, but we realize that families have limited days off to bring in their children. We try to help by addressing many of the concerns so you do not have to return. Sometimes it is not appropriate to tackle too many issues (none will be covered adequately if too many are attempted) and we will ask that you schedule another appointment. Things that go together, such as cold, cough and earache are easily addressed at one visit. It is not possible to discuss chronic headaches, warts, asthma, and other complaints when a simple "sore throat" appointment was scheduled. This also applies to the list of questions and concerns parents bring to well visits. A well visit is designed to address safety, growth, nutrition, development, and other specific topics. Saving up a year's worth of concerns to discuss at that one appointment is not wise. It does not allow time to devote to each issue appropriately. We ask that you come in for separate visits as needed and not wait to discuss everything at one visit.

• Siblings. Many times each day our providers are asked to “just take a look” at brother or sister. This innocent question seems to only take a few minutes, but these minutes add up by the end of the day. Since we will see all sick children on a same-day basis, please check in each child you want checked or discussed. If you just want to discuss another child without an appointment, call the nurse line or e-mail your provider through our web portal.

• Sometimes we joke that the bus just stopped by. There’s no one in the waiting room, then suddenly the waiting room is full of people. If someone's late to an appointment, someone else right on time, and someone early, then it gets backed up. Please be on time for appointments whenever possible and call if you will be more than a few minutes late. We understand that sometimes there is unexpected traffic or a child pukes during the drive, so we will always attempt to fit people in who missed their appointment time, but realize that it makes others wait. Do not schedule an appointment if you know you will be late. It’s amazing how often we hear, “It always takes so long to get from work to daycare and then to your office.” If it always happens, why not adjust your travel time to be at the office on time?

• We will see your sick child the same day during business hours. It is easy to pre-schedule well visits and follow up appointments, but it is difficult to anticipate how many kids will be sick on any given day. We track visit numbers by time of year, but there is variability. Our providers have more well visit openings in their schedules and fewer sick slots during the summer, but more sick visit openings and fewer well visit appointments during the winter. Call early in the day if you want to schedule with a particular provider. If a schedule is full, we do not "overbook" a provider. 

• Inappropriately scheduled appointments. It is difficult for our schedulers to know exactly how long an appointment will run, but they do attempt to schedule based on the concerns of the caller scheduling. For instance, a sick visit with ear ache, cough, or sore throat is typically well covered in 10-15 minutes, and is scheduled as such. If the child is actually wheezing and in need of breathing treatments, this becomes a long appointment where the provider will need to assess the child several times. Understandably the child needs this attention, but was not scheduled for a long visit, so other patients will end up waiting longer. Please attempt to be clear with your concerns when scheduling to allow proper time allotment for your appointment. 

• Insurance information and other “bookkeeping” issues. Please be ready with all current insurance information as you check in. If you have not filled in a Patient Information Sheet in the past 12 months, you will be asked to provide a new form. Filling this out at home is easier for most parents. You can print out and fill in our Patient Information Form ahead of time if you prefer. For all new patients and existing patients with insurance changes, our receptionists may need to call the insurance company to verify information, so please arrive 10-15 minutes early. Have your co pay ready. Again, it is amazing how many people have to run back to the car because they leave their wallet there. (Never a good idea, by the way... thieves love wallets in cars!)

• Physical forms. Often high school age kids come in for sport and camp physicals without the required form filled in. The form MUST be completed before the provider can sign it. Many of these forms are detailed and take time to fill out. Please fill out your forms before coming to the office. If you do not have a form, click here.

• Behavior. Some parents spend an extraordinary amount of time disciplining their children in our office. Often it is the sibling of the child with the appointment, not even the child being seen. We know that all children are rowdy sometimes, but it makes the visit long if we have to repeat what is said multiple times because the parent was distracted by the child, or if we have to wait for the parent to calm the child down. Bringing only the child(ren) with appointments helps this situation. If a child resists being weighed and measured, it takes the nurse longer to get him ready and the next patient might be ready before you, meaning you might end up waiting longer for the provider. If the child fights an exam (very common between 12 and 36 months) it takes longer to adequately evaluate the child and extends the provider time in the room, making the next patient wait longer. We expect and understand this, but it still adds time to our day, and if we have several of these children in a row, it slows us down. 

• Walk-ins. We offer an urgent care walk-in clinic daily. We staff this based on time of year and expected volume of patients. Obviously without scheduled appointments, this is at best an educated guess. Try arriving before the last 30 minutes of walk-in, as this is the busiest time. It usually has fairly short waiting times and you don't need to spend time calling to schedule then waiting for your appointment. (A benefit to our walk in clinic versus another clinic around town is that we have your child's records and the visit will be added to your child's permanent health record. We know you and your family. By seeing us, you help us keep current in your child's health.)

What can you do to help?

• Try to be on time. If you will be late, please call. Your appointment might only be set for 15 minutes, so arriving just 10 minutes late nearly misses it altogether. It is not possible to shorten the actual visit, so we will now run late for everyone else. We may ask people who are late to see another provider to lessen the disruption to others. 

• Arrive no more than 5 minutes early or warn the staff that you are early. People who arrive early are just as disruptive to a schedule as those who show late. Although you might luck out and show up early when someone else has called that they are running late, but it rarely works that way. Early patients take front office staff and nursing time away from people checking in on time, and may put people scheduled ahead of them back in line. Kids learn early in school "no cuts" and this is the same concept. We attempt to keep track of who is being seen and order them in order of appointments, but some patients show up early and then are upset at the "long" wait time and their kids are out of control in the room from boredom of the extra wait time. 

• Schedule your appointment appropriately. Scheduling for an earache when you really want to discuss the implications of your divorce on your child's behavior is not appropriate. An earache is a short appointment. Chronic conditions, behavior concerns, and well visits are long visits on the schedule.

• Be flexible. If the provider you scheduled with is very busy due to unexpected issues and you are offered to see another provider, please consider this option. If you want to see only the person you scheduled with, remember you will wait longer. If another provider has an opening, you will get more prompt (but still great!) care.

• Avoid scheduling during nap or meal times. Being tired, sick, and hungry makes kids more irritable, can prolong visits due to behavior problems, and makes the visit less valuable due to difficulty holding a conversation, answering questions, and staying on task. (Please avoid giving children snacks in the office. It can be a real problem for others with food allergies.)

• If you must leave by a specific time, let your nurse know. She might suggest seeing another provider if the one you are seeing is delayed.

• Bring only the child scheduled for an appointment if possible. This allows the focus to be on your child that is being seen, and not on the fighting and running around that happens with siblings. Also, there is less exposure to the germs in our office, so you don't make a trip back a few days later with a sick sibling!

• Schedule all children you wish to have seen or discuss.

• Have your insurance card and co payment ready at check in.

• Pre-fill out any forms needed: Camp and Sports forms and our Patient Information Sheet.

• Schedule early in the morning or afternoon - less time for us to get hung up with another patient.

• Bring books or toys (this is a great time for hand held electronics) for your child to stay occupied with during the wait to make it seem shorter for all!