Going to a new place for convenience

My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there's always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.

Image source: Wikipedia

But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home. Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well... convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent. While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks. The food wasn't the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn't of any use helping me decide if what we ate was good for us or not. Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there. Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it's usual for Convenience Cooks to bill added fees.

In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but don't offer slow-cooked BBQ, so they refer customers to BBQ-R-Us. But BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation. When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask if you should have gotten the burnt ends or the ribs. Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee.

Most people can see just how crazy it is for a restaurant to "fix" the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or after we refer to a specialist. The scenarios above are based on real phone calls about medical care.

Convenience Cooks = Urgent Cares

I'm sure I'm not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn't fixed at an urgent care. I am glad that patient families feel so comfortable with my office that you will call to ask for help, but if I am not a part of the evaluation, I can't help.

Many problems seen at urgent cares can wait. I know it's easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it's strep throat and they start an antibiotic at 8pm, they can't go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night. The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)

If your child was having an issue that did need to be seen ASAP after our office hours, we would have referred you to an urgent care that has quality pediatric providers we trust and sends us a written report of what happened. Even with that, sometimes we need to see a patient on follow up to ascertain if a treatment plan is working or if it needs to be changed.

If you call us because your child is having an allergic reaction to a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that "they're not open yet" or "they don't do phone calls, they want us to come back." Sorry. We will want to see your child before we treat him for this issue.

BBQ-R-Us = Subspecialist Referrals

As for specialist referrals, I know it's hard for people to wait for appointments, but I really can't get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. But usually it isn't really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I'm not saying that's a good thing, it's simply reality. Please don't beg me to call them to get you in sooner. I cannot invent time and I can't alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I've done this frustrating scenario many times-- often when I really want the child seen sooner than scheduled. Unfortunately, it usually doesn't significantly alter the appointment time.

After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it is usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don't like to "step on toes" if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road.

Expect higher fees any time you use a hospital based facility, whether it's for an office visit, a lab, or a procedure. They not only have charges for the physician's time, but they have facility fees to cover the costs of running the hospital. Of course the primary care physician cannot affect the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do... I can't even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that. It is hard to anticipate costs, and that is a problem with our healthcare system. I know that, but it is not in my control to fix that. We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn't help plan before the visit. I understand how that's frustrating, but I can only help with what is in my control. I cannot control how our billing and insurance system works and another office's charges are in no way under my control.

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.

Evolution of Illness

When kids are sick, parents understandably want them to feel better quickly. They want a sound night's sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.

Sometimes there is no quick fix, just treating symptoms and time.

This is the season we are seeing a lot of sickness. It's been about 11 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn't help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn't make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments (because my son had wheezing so we had everything we needed to give a treatment at home) despite the fact that they didn't seem to help her much. It was probably the humidified air that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn't helping, so I wanted to at least try the asthma medicine. She kept wheezing. We brought her in to the office 3 days in a row to have someone else check her. I can't check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams. She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times/minute for days. I still don't know how. I remember wishing her oxygen level would drop enough that we could hospitalize her, not critically, just enough. Then she'd be on monitors, and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick, and eventually we were all sleeping again, but it took a long time for that.

So I understand the frustration when we tell parents things to do at home and ask that they come back in  __ days or if ___, ____, ___ symptoms worsen. It really isn't that we are holding out on a treatment that will fix the illness, it's just that we don't have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.

The exam can tell us a lot, but it doesn't predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I've heard a parent complain that someone else "missed" something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.

I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse called because a fever had started. New symptom, so another exam was done. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.

I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don't resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.

When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.

Money is probably the biggest issue. It is not because we want your co pay. The "we" I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I've seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the co pay because we did "something wrong" or "missed a diagnosis" the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate co pay is charged. We must adhere to legal contracts or it would be considered insurance fraud.

Increasing our numbers for "production" is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don't want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.

We want to see your child again because we need to see your child to know what to do. Maybe now the child's symptoms have changed.  Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever's been going on long enough without any identifiable cause, which requires lab and/or xray evaluation. 

Please remember that if you get a different answer at a different visit, it doesn't mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change. Human bodies are not static.

Decisions Parents Make: Use all the facts

Parents struggle with decisions

I was recently asked to clarify a comment I made on facebook, and the comment deserves more than a quick facebook blurb.


The original post:

If you ever plan on having kids, PLEASE make sure you educate yourself about this!

Myths about Circumcision You Likely Believe | Psychology Today

www.psychologytoday.com

CIrcumcision does great harm to babies By Darcia Narvaez, Ph.D....

My reply:
This is one way to use "studies" to distort facts. This article has so many inaccuracies I don't know where to start. 

One of the great things about our country is we have freedom of speech.  I highly support everyone being able to state their opinion, including those who disagree with my opinion.  But I also think we all need to look at opinions as opinions, not as hard fact.  Read articles critically and form your own opinion. Read articles from both sides of the line before you draw your conclusion.  When authors have an agenda (which is why most writers write, including myself here) you must be able to see when they are able to share both sides of a story and when they are simply stating the facts that support their cause.  I am not saying that it is wrong to just state your opinion, just that readers must know how to filter the information. I personally dislike/hate when an argument is actually based on emotion and fears, but comes off as science.  Too many parents are made to feel guilty because they have made a choice for their child that differs from a friend or relative. They read something that differs from what they did and they feel like they made the wrong choice. Regret is a dangerous thing, and is often misplaced.

The intent of my facebook comment above is not to support or discourage circumcision, but rather to warn that when authors have a strong agenda, the methods of persuasion often cause doubt and guilt in readers. I do not find this to be helpful in any way. Data and statistics can be used to distort reality, especially when studies are hand picked to only discuss the ones that support your cause and the ones supporting the contrary are omitted. This includes not only circumcision, but also breastfeeding, vaccines, home schooling, discipline, religion, government, and many, many other topics. 

The first clue that this is an article with a cause is the title and subtitle: “Myths about Circumcision You Likely Believe  CIrcumcision does great harm to babies”.  Simply reading this title alerts the reader that the author is going to persuade you that circumcision is a bad thing.  Their argument is one side of the circumcision debate, but you need to read the counter point from someone who supports circumcision before you make a decision.  

As a disclaimer and credentials for why I feel I can give an educated opinion:  I am a pediatrician who has performed many circumcisions during my 13+ years of private practice. I let parents make the decision to do or not do the circumcision and do not try to sway their decision in any way. I invite parents to watch every time, and nearly half of boys have one or both parents present. Typically parents are impressed by the overall brief procedure. Many have commented that it wasn’t as bad as they thought it would be. I have never had anyone comment how bad it was and have never had anyone (parents, nurses, medical students, or nursing students) become physically ill from watching. I admit that it could be awkward for a parent to express negative comments, so they could simply keep their thoughts to themselves, but experience tells me that when people are upset about things, they tend to complain.  So the many positive comments without any negative comments supports that parents have a generally good feeling about their decision even after watching the procedure.  Note: parents are self selecting here. The parents who don’t want a circumcision in the first place don’t agree to the procedure, and the parents who don’t want to watch are not able to comment on the actual procedure.

Starting with myth 1.  The foreskin is the distal skin of the penis and is removed during the circumcision. It is true that it is adhered to the glans of the penis in a newborn, and there are several means to break these adhesions. This is the most painful part of the circumcision in my opinion (but with adequate pain relief, this pain is diminished/eliminated-- see #3).  As for the surface area of the foreskin in an adult male, I do not see how that accounts for anything about a newborn’s circumcision. A newborn does not have 15 square inches removed. Adult males have wide variation in penile size, and therefore foreskin size.  What has been documented is the more foreskin surface area, the more likely a male will suffer from sexually transmitted diseases:

• Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis: Tobian A.A.R. et al. (2009) 

• Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters) 

• Foreskin surface an  HIV acquisition  

Myth #2.  Procedures hurt, but that doesn’t mean pain isn’t managed. I agree that anesthesia helps, and this has been shown by several studies. The small study by Lander the author mentions shows that the best form of pain control is with the ring block, which injects lidocaine around the base of the penis. However the only form of anesthetic mentioned in the Myth article is the dorsal block, stating that it is the most common. In reading the article by Narvaez, it is stated that one patient in Lander's study suffered a seizure. Reading Lander’s summary, it appears the baby had apnea and loss of tone in the limbs. While this could represent a seizure, it could also be a choking episode, which is common with newborns feeding or crying. I have seen these in many newborns not associated with any procedure. It is difficult to presume it was a seizure from this documentation, and the conclusion of a direct cause/effect from the procedure cannot  be certain. The small sample size of the study limits the validity and generalizability of any findings, including problems encountered. I personally use sucrose pacification (sugar water on a parent or nurse finger or a pacifier) plus a ring block. Neither of these were mentioned by the author. Sucrose pacification has been shown to help with painful procedures the first 4 months of life. I use it to decrease the pain associated with the injection of lidocaine for the ring block and throughout the procedure. I find that babies tolerate the procedure very well the large majority of the time. What also wasn’t mentioned is that there are many types of circumcisions. Training of the physician typically dictates method used, but they each have their own risks and benefits and pain scores.

Myth #3.  See also #2. I do not know where the 45% of doctors using anesthesia number comes from. In my geographic area at the 4 hospitals in which I take care of newborns, anesthesia of some sort is used by all physicians doing circumcisions to my knowledge. In my area it is typically the pediatrician who performs the circumcision, and few obstetricians do it, not OBs.  As for it taking 30 minutes to achieve anesthesia, I have no idea where that number came from.  Local anesthetics have rapid onset once injected. Lidocaine takes 0.5-1 minute, prilocaine 1-2 minutes.  Topical preparations do take longer and should be placed at least 30 minutes prior to the procedure, and they are much less effective in general than injectable anesthetics.  

Myth #4. I cannot understand how this can be reliably tested. The process of birth itself is traumatic. The large majority of boys in the United States are circumcised, but I do not need to treat the majority of boys for Post Traumatic Stress Disorder. The choice of pain relief by Taddio in his studies (referenced in the Myth article) was a topical anesthetic, which is not as effective as other forms of anesthesia. This highlights that you can formulate the methods of your study to get the answer you are looking for, not necessarily the whole truth of the matter. If Taddio really wanted to prove that anesthesia made a difference, the choice of anesthesia should have either included several types ~ or at least the most efficacious, not the least.  Linking long term effects to a single newborn experience would be impossible in my humble opinion because there are too many confounding factors and it is impossible to isolate a single cause/effect relationship.  This is simply a ploy to get parents to regret a choice they have made for their children. This is horrendous in my opinion. We have many opportunities to feel guilt, please do not try to make parents feel guilty about a choice they have made that can impact the health of their son.

Myth #5. Yes, some babies sleep comfortably during the procedure. I have many parents that can agree with this statement after watching their sons undergo the circumcision.  Their babies did not cry themselves to sleep or go into a shock state. They were just sleepy babies. Most do not sleep ~ after all we are stimulating them by moving them around, washing the area, and otherwise touching them.

Myth #6. There are risks to all procedures. A physician should discuss the risks and benefits prior to the procedure. Parents have the right and responsibility to make choices for their children.  Of the complications listed, these are not unique to circumcised males. 

• Meatal stenosis is a narrowing of the urethra that both boys and girls can have, not necessarily after circumcision.  It can be a complication of circumcision from irritation, but is rare.

• Adhesions are NORMAL.  I mentioned above (Myth 1) that they must be broken to remove the foreskin. Without a circumcision they tend to release by 6 years of age. Some circumcised boys re-attach the foreskin without any need to do anything since they typically release on their own by 6 years of age. This is especially common if the pubic fat pad pushes the skin of the penis up and buries the penis (see next item).  While some physicians recommend breaking these adhesions, I have found that it is not required to break these attachments in most cases. This has been validated by Ponsky et al at Penile adhesions after neonatal circumcision. Rarely boys develop bridging adhesions which are different, and these do need to be repaired. 

• Buried penis is common when infants have a thick fat pad at the base of the penis. This happens in both circumcised and uncircumcised boys. It has nothing to do with the amount of foreskin removed. The worst I ever saw was in an uncircumcised toddler. He suffered complications to the point where he needed a circumcision as a preschooler to resolve the problems. This required general anesthesia which involved greater risk than neonatal circumcision.

• Infections are possible any time the skin is broken, yet I have never seen an infected circumcision. It is a risk that should be discussed prior to the procedure so parents know how to identify it early and seek help.  Poor sterile technique has been associated with infection and has made the news earlier this year. If done in a hospital setting with proper technique this risk is minimized. Those having a bris should find a qualified mohel with a good record for safety and proper hygiene.

• Death is very rare. Risk factors, such as family history of bleeding disorders should be discussed prior to the procedure. Vitamin K should be given prior to procedures to decrease risk of bleeding. After the circumcision the site should be routinely checked by trained persons to assess for bleeding. See also infection risk above.

Of course no mention of benefits was made by the author. This unbalanced view does not allow a full disclosure of both sides. 

• A significant decrease in sexually transmitted diseases has been shown among circumcised men. 

• Urinary tract infection risk can be decreased in infants. 

• Phimosis and balanoposthitis are infections caused by improper cleaning of the uncircumcised foreskin. I have seen phimosis once when working as a nurse assistant in a nursing home. It was painful and a horrible consequence of care takers not knowing how to care for the uncircumcised penis. Can this be prevented? Yes. But in our country where most men are circumcised, it is not common knowledge. 

• Improved hygiene in general is easier in circumcised males. I have instructed many families on how to care for the penis, but find that many boys don’t care for themselves properly as they become independent in the shower. Parents need to discuss this with their uncircumcised sons often!

• A decrease in penile cancer risk after circumcision.  

My intent on writing this is not to support or condemn circumcision, it is to simply show how only looking at one side of any conflict can lead to confusion and misinformation.  Learn to look at both sides of an argument to make a better informed decision that is right for you! Don't judge others for their decisions, and don't feel regret for decisions you made based on the information you had!

Walk In Clinic Etiquette

Cold and flu season always brings more people to the doctor or health clinic.  The pure volume can be overwhelming for any clinic, scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable.   Sometimes no one in walks in, other times several come at once.  Walk in clinics are wonderful for the overall rapidness at which one can be seen, but how can you help streamline the process?

1.  Write down symptoms.  It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details.  Writing things down helps everyone summarize what is going on and get facts straight.  Very often the diagnosis lies in the history, and if the person bringing the child in does not know symptoms well, it is difficult to make a proper diagnosis.

2.  Expect to be seen for one acute problem.  Illnesses typically have more than one symptom, but they are a single illness.  It is appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat.  It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on.

The nature of walk in clinics is that they move rapidly.  The number of patients checking in at any given time can be large, so each visit must be quick.  If you need more time with a provider, schedule an appointment.

3.  Do not attempt to get care for a chronic issue.  Chronic issues are always best managed by your Primary Care Provider (PCP).  This does not include sudden changes to a condition, such as wheezing in an asthmatic.  Your child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing.  This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.

4.  Do not add additional children to the visit. Many parents bring additional kids to the visit and ask if we can "just take a peek" in their ears. If you want them seen, check them in too.  Again, walk in clinics move quickly and the "quick" peek takes longer because the child is running around the room or fighting the exam.  The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.

5.  Have your insurance card and copayment ready at check in.  Streamline checking in by having everything ready.  It is amazing to me how many people must return to their car for their wallet.

6.  Try to bring only the child who is being seen.  It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions.  This applies to scheduled as well as walk in visits.  I know this becomes a childcare issue, but it can really help focus on the child being seen.

7. Bring medications your child has recently taken.  Often parents have tried treatments at home, but are not sure what was in the bottle.  Bringing all medications (prescription and over the counter) and supplements helps us advise on correct dosage and use of the medications.

8.  Go to a walk in clinic at your regular doctor's office if available.  I know not all doctor's offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent, they can wait until the next business day.  Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days.  This might even be beneficial to improve the immune system's ability to fight illnesses and to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!

The benefits to going to your regular doctor's office to see your PCP or another provider with access to your child's medical record are many.  The record has your child's immunization history,  previous drug reactions, any underlying illnesses or frequency of illnesses (as long as you use them exclusively), as well as any other pertinent information.  Primary Care Providers and their staff also know your family and that alone can help!

Some walk in centers limit services or ages of patients.  The provider at the clinic may or may not have adequate training in pediatrics, and they often do not have others around who can help if a problem arises that is out of their comfort zone.   If a baby is crying, the eardrum gets red, but isn't necessarily infected.  A provider without a lot of experience will often err on calling it an ear infection. Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary.  Better satisfaction scores for the clinic.  Faster turn around time since it takes longer to explain how to treat a cold than it does to write a quick script.  Everyone's happy, but antibiotics are overused.   They also do not offer follow up of issues to see if there is improvement.  They do not take phone calls if there is a followup related question.  You must call your PCP, but if we haven't seen the child for the issue, we are unable to give appropriate advice. 

There are gaps in care even at urgent cares where there is a pediatrician or midlevel provider with extensive pediatric training (there is more than one option in this area).  They do not know your child's full medical background and do not update your child's health record in the medical home.  Following in one office allows us to see the chronicity or recurrence risk of an issue.  If your child goes multiple places for every sore throat, the PCP only sees him for well visits and no one recognizes that a tonsillectomy might be beneficial. 

9.  Please don't use walk in clinics to have health forms filled out.  I know it is tempting to get a quick physical just to have the sports form or work physical signed, but this breaks the concept of a medical home.  Your regular doctor doesn't get to see you for a comprehensive visit, reviewing growth, development, safety, immunization status, and more. We lose the opportunity to share what has happened in the past year and continue our relationship.   If the medical home does all the well visits and vaccines, we have up to date records and can update as needed.  Some kids have missed school because vaccines were missed and they can't return until they get them.  Others have gotten extra doses of vaccines because a record of a shot was missing and parents can't remember where they got the vaccine.  We request a well visit yearly (after age 2) within the medical home.  If in need of a well visit, please call the office to schedule! 

Cold and Flu Season is Upon Us!

photo source: Shutterstock

As cold and flu season approaches, I have been thinking about how our kids are managed when they become sick.  Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.


We are a busy society.  We want things done now.  Quickly. Cheaply. Correctly.  Resolution so we can get back to life.


Illness doesn't work that way.  Most childhood illnesses are viruses and they take a few weeks to resolve. There's no magic medicine that will make it better.

Please don't ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.  

Don't ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.  

Don't ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.  

Antibiotics simply don't work for viruses.  They also carry risks, which are not worth taking when the antibiotic isn't needed in the first place.

Many parents in this community have grown accustomed to using after hour urgent cares  because they are convenient.

Convenient isn't always the best choice.  Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours.  I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?  Can it hurt?

Some kids will get unnecessary tests, xrays, and treatments at urgent cares that don't have a reliable means of follow up.  They attempt to decrease risk often by erring with over treating.  Our office does have the ability to follow up with you in the near future, so we don't have to over treat.  

Urgent cares don't have a child's history available.  They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).  They might not recognize if your child doesn't have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.  We know that parents can and should tell all providers these things, but our own new patient information sheets are often erroneous when compared to the transferred records from the previous physician... parents don't think about the wheezing history or the surgery 5 years ago every visit.  It is so important to have old records!

There is some evidence that treating things too soon does not allow our bodies to make immunity against the germ.  A great example of this is Strep throat.  Years ago we would go to a doctor when our sore throat didn't get better after a few days.  They would swab our throat and send the swab for culture, which took 2 days. We would treat only after that culture was positive.  That delay in treatment allowed our bodies to recognize the Strep and begin making antibodies against it.  Now kids are brought in the day they have symptoms, and if the rapid test is positive, they immediately start antibiotics.  The benefit? They are less likely to spread Strep to others and they can return to school 24 hrs after starting the antibiotic.  The negative? They might be more susceptible to recurrent illness with Strep, so in the end are potentially sick more often and end up missing more school.

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.  Is it time for further evaluation of immune issues?  Is it time to consider ear tubes or a tonsillectomy?  If we don't have proper documentation, these issues might have a delay of recognition.

Urgent cares and ERs are not always designed for kids.  I'm not talking about cute pictures or smaller exam tables.  I'm talking about the experience of the provider.  If they are trained mostly to treat adults, they might be less comfortable with kids.  They often order more tests, xrays, and inappropriate treatments due to their inexperience.  This increases cost as well as risk to your child.  We have been fortunate to have many urgent cares available after hours that are designed specifically for kids, which does help.  But this is sometimes for convenience, not for the best medical care.

Cost.  As previously mentioned, cost is a factor.  I hate to bring money into the equation when it comes to the health of your child, but it is important.  Healthcare spending is spiraling out of control.  Urgent cares and ERs charge more.  This cost is increasingly being passed on to consumers.  Your co pay is probably higher outside the medical home.  The percentage of the visit you must pay is often higher.  If you pay out of pocket until your deductible is met, this can be a substantial difference in cost.  (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about our urgent care in our office?  We offer a walk in urgent care as a convenience for parents who are worried about their acutely ill child.  It is within the medical home, which allows us access to your child's chart. We can keep all treatments within this medical record so it is complete.  Our staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols our physicians and midlevel providers have agreed upon.  Essentially we have a high standard of care and want your child to receive that great care.

So what kinds of issues are appropriate for various types of visits?  
(note: I can't list every medical problem, parental decisions must be made for individual situations)

After hours urgent care or ER:

• Difficulty breathing (not just noisy congestion or cough)
• Dehydration
• Injury
• Pain that is not controlled with over the counter medicines
• Severe abdominal pain
• Fever >100.4 rectally if under 3 months of age
  

Pediatric Partner's Urgent Care:

• Fever 
• Ear ache
• Fussiness
• Cough
• Sore throat
• Vomiting and/or diarrhea
• Any new illness

Issues better addressed with an Appointment in the Medical Home:

• Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
  
• Chronic (long term) concerns (growth, constipation, acne, headaches)
  
• Behavioral issues
  
• Well visits and sports physicals (insurance counts these as the same, and limits to once/year)
• Immunizations - ideally done at medical home so records remain complete 

If your child gets a vaccine at any other location, please send us documentation (including the date, brand, lot number, and place administered) so we can keep the records complete.

Remember our website offers answers to questions and many treatments to try at home for various illnesses and conditions!