Private discussions with the pediatrician

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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.

 

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.

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! 

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!

On the Job Training for Doctors?

A recent report showed a large discrepancy between what pediatricians believe they should do to advise parents and kids on sleep, and what they were actually trained to do, which begs the question: What are pediatricians NOT trained to do but must do as a routine part of their job?

What is this discrepancy?  The Journal of Pediatrics published a report that only 18% of pediatricians reported having formal training in sleep disorders, but 96% felt it was their job to treat them.  Their conclusion is that training programs should provide sleep education.

While on the surface this sounds like a great idea, reflecting back on my training and early years in practice, residency would have to be extended by many years to teach all that I need to know at my job. Teaching sleep hygiene (or not teaching it) is just the tip of the iceberg. Not to mention that there is new information all the time about how to do things better, so the learning should really never end.

I learned about car seats after my son was born during the end of my 3rd year of residency.  

How did I make it 3 years without learning about car seats???  I would simply mention to parents to be sure to use one.  If they had specific questions about if the baby was properly in the seat, I referred them to a car seat expert.  (We refer to a lot of experts in residency.)

We took my son home from the hospital on an icy February day in a warm jacket  buckled into the car seat.  When we got home and I went to unlatch the buckle I realized it had never clicked. The jacket was too bulky!!!  We went to a car seat check a couple weeks later and his car seat wasn't even tight enough ~ this is before the LATCH system helped secure the seat.  My own baby had been unsafe.  How awful is that after nearly 3 years of pediatric residency?  Of course now, 12 years later, many car seat rules/recommendations have changed.  Gotta keep learning!

I had a little formal education about breastfeeding, but it was mostly the technical aspects of how milk is produced, not how to help a mother/baby be successful with breastfeeding.  That I learned when struggling to breastfeed my first baby, and along the way with other moms and their various problems.  My second came along and breastfeeding went great, but she wouldn't take a bottle.  Boy, did I learn a lot from my own kids with two very different feeding problems.

I don't remember a single lecture on nutrition, though I'm sure we had them.  Not much on exercise that I recall.  These would have been considered "easy" topics and as a resident we were more focused on studying acid base disorders and intricate diseases because that would be what we would be tested on.  I wish I learned more about nutrition and exercise psychology because of the current level of obesity, but it is a relatively new problem in pediatrics -- one even the specialists aren't sure how to manage. 

It is estimated that 40% of primary care visits involve behavior problems, yet I only had a single one month rotation on psychiatry.  I am still learning new tricks 12+ years into practice.  Many of my experiences as a parent color what I have learned in this arena.  I also have the privileged position to learn from the families I see at work.  All of this information I use to counsel families about these issues.  I could never have learned this in a lecture, or even in a clinic with a preceptor for a one month rotation.

Simple things, like what to do with a baby who has a nose filled with mucus, were not discussed in lectures because there were more advanced things to learn, like how to manage a child on a ventilator.  I don't ever manage ventilator's now, but I had to learn how in residency.  Why learn that?  Because it teaches doctors to think.  

We need to learn the basics in school about how the body works.  The psychology, pharmacology, physiology, and all the other -ologies.  

Residency teaches us how to apply these things to the human person.  Treating the sickest of the sick in the hospital setting teaches us to recognize sick and become independent learners.  


Starting up in practice teaches us more about common illnesses and concerns. We sharpen the skills of disease management and normal growth and development with all of its variances from following the same kids over years.  We must incorporate everything we know from books, lectures, clinical experiences, personal experiences, and more into caring for our patients with the most current evidence based and practical methods available.

And that keeps changing, 

          keeping pediatricians life long learners!