What should I do after hours when my child is sick?

Parents often fret about whether or not to go to the ER (or urgent care center or walk in clinic) for a child's illness or injury. This week the American Academy of Pediatrics released a position statement against walk in clinics. Many parents don't realize the difference between a pharmacy walk in clinic and an urgent care or ER staffed with pediatric - trained physicians, nurse practitioners, and physician assistants. I believe that urgent needs do arise after office hours, and we are fortunate in our area to have pediatric urgent cares and ERs that can fit that need.

This post is written with my own practice patients in mind. There are variances in what is available in any community and what  a pediatrician is comfortable seeing in the office and what they refer out. Please speak with your own physician about what to do after hours in your situation.

photo source: Shutterstock

I also know that many parents take their kids to walk in clinics for convenience. Sometimes even when our office is open. I think that really fragments the healthcare of the child and I cannot support going outside the medical home when unnecessary. I've blogged about this before. Please visit Urgent Cares for Routine Illnesses... Yes or No for more on that topic.

When to call for after hours advice

Over the years I have found most of my patient families to be very respectful of after hours phone calls. They recognize that I am trying to spend time with my family or that they woke me from sleep. They often apologize for bothering me (which isn't necessary, it is my job). Only on rare occasions do they call for things that should have been called during office hours or in true emergencies where they should call 911. It is a reasonable call if you need help managing the symptoms your child has, especially if you can't find your answer on our searchable website. If you want a diagnosis or prescription, your child will need to be seen and evaluated.

Things to avoid calling the on call provider about:

• To schedule an appointment. We don't do that. Leave a message at the office or request an appointment on our portal.
• To cancel an appointment. Leave a message at the office for the office staff.
• Any billing question. 
• To ask when we open. That information is on our website and our office outgoing voicemail message.
• To discuss a chronic issue that you have been working on with your primary provider -- unless symptoms have worsened and you need treatment advice.
• To discuss treatment from another office, such as a walk in clinic not in our office or a specialist that is managing a chronic illness. If you question something done by another provider, talk first with that provider. If you want to discuss it with your primary physician, call during office hours or send a message through our portal. 
• Prescription refills. It is a very unusual circumstance that we would call out a refill for you.
• A diagnosis and prescription. We cannot make a diagnosis over the phone and cannot prescribe a new medication for something that hasn't been seen.
• Rashes. See below.
• Symptoms that have been ongoing for days but not worsening. If symptoms have been stable for days, it can wait until we are open for your child to be seen.
• Routine growth, development, or behavior questions.
• Routine lab results. Sometimes our nurses call with lab results, but must leave a cryptic message. (Due to HIPAA laws they do not leave specific information on voicemail-- another reason to be sure each of your children are registered on our password protected portal-- we can leave specific details there!). If it is a result that requires notification of the parent urgently, they will tell the on call provider to call you or they will give you instructions to call back (with the knowledge of the on call person). If they say to call back during business hours, the on call person does not have your results on hand.
• To "document" suspected abuse. These kids should always be taken to a place that can see your child directly and has staff specifically trained for that purpose. We usually recommend an emergency room, such as the ones at Children's Mercy campuses. A phone call is hearsay and would not help your case.
• Directions to an urgent care or ER. I don't give good directions, just ask my husband. Call them, look online, or set a GPS.
• Prior authorization before going to the ER or an urgent care. We cannot do PA's after hours and they are not needed for insurance companies.
• To learn if a particular location is covered by your insurance. Call that location or check with your insurance company. We won't know. 
• To ask if an urgent care or walk in clinic provides a particular service, such as possible urinary tract infection in a toddler or stitches. We won't know. Call them for information about what they do.
• Anything that needs to be treated urgently. Calling us delays care. We can be notified later. Just go. 
• And one last request. Please don't call from the ER or urgent care waiting room to ask if it's okay to leave because the wait's too long. If you thought symptoms needed to be seen in the first place, I would never feel comfortable telling you to leave. Ask someone there who can see your child.

How can you find answers if you don't want to call after hours? 

• For our patients, using our online portal allows parents to ask routine questions at any time of day/night, as long as they can wait up to 5 business days for a reply. 
• Our website has a ton of information to treat many symptoms and parents can search there before calling. (Parents will often say, "I looked on the website but didn't find..." so I know they try! Thank you for trying!!! It not only helps the on call provider not be bombarded with another call, but you will often get more thourough advice, especially in the middle of the night.) 
• Online searches can be helpful ONLY if you know the site you are using. Besides our own website, you can use HealthyChildren, KidsHealth, or recognized hospital websites, such as CHOP.

• Remember: We are open 6 days a week and we offer walk in hours all open business hours. This allows you to come in to our office for most illnesses and minor injuries.

For more on how to get the best phone advice when you call our office or after hours on call provider, please read Help Us Help You.

Times to go to the ER or Urgent Care: 

The big question in a parent's mind is when does a child need to be brought to a walk in clinic or emergency room. If in doubt after reading this, call the on call provider for specific advice. Some generalizations to help make the decision:

• Any temperature over 100.5 in a baby under 2-3months of age. (I usually say at least 2 weeks after the 2 month vaccines.) A pediatric specific ER is best for this unless our office is open. (We can do the initial evaluation if we are open.)
• Any temperature over 100.5 in an under-immunized or immune deficient child. Be sure to tell the providers of the medical history that makes your child high risk. We can see these kids when we are open. An ER, ideally pediatric specific, is best for this when we are closed.
• Signs of dehydration. This includes no tears, dry mouth (not just lips), no urine in 6-8 hours. Dehydration can be managed in some urgent cares and all ERs. (Call the urgent care to see if it is within their scope of practice.) Walk in centers are NOT generally equipped to manage dehydration. Our office can see these kids if we are open. 
• A child who is urinating a lot but still seems dehydrated based on dry mouth, weight loss, sunken eyes, etc needs to be seen immediately. This is a sign of diabetes and needs to be seen in an ER if we are closed.
• Signs of respiratory distress. This includes breathing faster than 60 times / minute in children under 1 year, 50 times / minute in older children. This can be treated in our office when we are open, or in a pediatric urgent care or ER. Walk in centers should be avoided due to provider variations in competence with respiratory distress.
• Excessive pain. If you can't control the pain with simple measures, such as acetaminophen or immobilizing a hurt limb, it should be evaluated. ERs are more suitable if it is a possible surgical issue or if imaging will be required.
• Gaping skin. If an injury causes the skin to open enough that it looks better if you pinch it together, it probably needs to be repaired. Stitches, glue, or staples need to be put in as soon as possible because the longer the wound is open the more likely it will become infected and after several hours we can no longer close it up. ERs will always do wound repair. Some urgent cares will. Walk in clinics generally do not. During office hours we can do laceration repair, so you can save the trip to the ER if we're open!
• Altered mental status. If your child is so lethargic he can't lift an arm to drink, or doesn't seem to recognize you, or doesn't make sense when talking he needs to be seen immediately in an ER.
• Parental comfort. This is a vague one, but I am a big believer in the gut feelings of a parent. If you are worried and can't sleep, there might be something going on. Of course, you can't second guess every illness or injury, but if you are so worried you can't sleep: go.
• Call 911 and go to the ER if there is a severe illness or injury that may be life threatening.
• Go to the ER if you suspect your illness or injury might require surgery. 
• If you suspect an x-ray will be needed after an injury, use an ER or urgent care with the ability to do X-rays. During office hours our office can handle minor injuries. If you suspect a broken bone but the child is not in extreme pain, there is no obvious angling of the bone, and the skin is not broken over the area, it may be okay to wait until our office opens.
• A child who loses consciousness after injury or with illness generally should be seen. Call 911 if consciousness does not resolve quickly. (Note: many kids will "pass out" when standing in a hot room or singing, when toddlers cry hard, when kids see blood, or if they hyperventilate due to excitement or pain. They usually awaken quickly from these episodes. If they act normal after this brief passing out time, they can generally be seen in our office. Call for advice.)
• Eye injuries that involve a puncture to the eye, a possible fracture of the bone around the eye, unequal pupil size, bleeding from the eye, vision changes, or other serious concerns should be seen in an ER. (Minor eye injuries, such as a possible scratch to the eye, can be seen in our office or a pediatric urgent care.)
• Seizures should generally be seen in an ER (unless there is a history of seizures and home treatment is available). If your child is running a fever when the seizure starts, call for instructions. It might be appropriate to be seen in our office or a pediatric urgent care.
• Allergic reactions involving hives or facial swelling can be seen in our office when open, an ER or pediatric urgent cares unless difficulty breathing (in which case, call 911 and go to the ER). Even if your child has epinephrine available, they need to be seen after epinephrine is used.
• Severe difficulty breathing should be called to 911 to be taken to the ER.
• Severe headache should be seen in the ER.
• Severe abdominal pain that does not allow the child to move normally should be seen in the ER. This could be a surgical issue.
• If you are unable to drive your child safely for any reason but they need to be seen, call 911.

Typical things seen at urgent cares or walk in clinics are things that usually would be seen in our office when we're open. Many can wait until we're open if you can manage pain, hydration, and breathing at home.

• mild wheezing or difficulty breathing that isn't worsening
• minor burns and injuries
• abdominal pain that is minor without dehydration
• constipation
• pink eye
• ear aches
• sore throat
• vomiting and diarrhea without dehydration (as discussed above)
• fever in children over 3 months of age who are immunized and immune competent
• objects in ears or noses 
• insect bites
• mild allergic reactions
• cough and colds
• skin rashes
• urinary tract infections 
• sports physicals should ideally be done at your primary care office so that growth, development, safety, and other issues can be addressed
• vaccines should ideally be done at your primary care office to keep all records in one place. If your child gets a vaccine elsewhere, be sure to call the PCP office during office hours to update their chart.

A few common concerns that parents call about:

Fever

Parents typically spend a lot of time giving me a play by play of all the temperatures of the past week.  I really don't need to know every up and down of the temperature. What does it really tell me if a child has a fever? They are sick. That's about it. There is no magic temperature that I worry about for most kids over 3 months of age. If your child is younger than 3 months, is not up to date on recommended vaccines, or has an immune deficiency, they need to be seen for any fever over 100.5F. For other kids, I care more how a child looks and acts than the temperature itself. The goal of fever management is to keep a child comfortable and hydrated. The American Academy of Pediatrics recommends treating temperatures over 102F and for comfort. The goal is not to bring the temperature to normal, but to allow your child to feel more comfortable. For more on fevers, see my Fever blog as well as our website's Fever page.

Rashes

Rashes are notoriously difficult to describe. I have a hard time documenting them in the medical record and will sometimes simply take a picture to put it in the child's chart. Even a picture doesn't completely tell the story because it does not show the texture, temperature of the skin, or the evolution over time of the rash. After seeing the rash we need to look for other findings that could be associated with that type of rash (such as enlarged lymph nodes, swollen spleen, swollen tonsils, mouth ulcers, etc). In general a rash needs to be seen to be addressed. Phone calls for rashes (even during office hours) are not helpful. It only needs to be seen emergently if there are significant other concerns. If the rash bothers the parent more than the child, schedule an appointment.

Ear Pain

Earaches generally are not emergencies. If you can control the pain at home with an over the counter fever reducer, you can usually wait until office hours. The exceptions: other symptoms, such as dehydration, difficulty breathing, or Mastoiditis -- If the ear physically sticks out from the head more than normal, it is an emergency. For more on earaches, see our Ear Pain web page.

Vomiting and/or Diarrhea

Stomach bugs are very difficult to manage, but usually can be managed at home. Follow the instructions on our Vomiting and Diarrhea page. Signs of dehydration include: dry inside the mouth, extreme weakness, no tears, and decreased urine (except with vomiting from diabetic ketoacidosis - those kids make a lot of urine but they otherwise look dehydrated). If you think your child is dehydrated, he should be seen. Diarrhea that is bloody, severe abdominal pain, and painful urination with vomiting are other times that being seen as early as possible is warranted.

Sore Throat

Sore throats can be painful, but with good hydration and no signs of difficulty breathing, they can wait until office hours.

Medication dosing

Unfortunately many over the counter medicines don't have dosing listed for infants and young children. We have common medications on our Medication Dosing page. You can also ask the pharmacist when you purchase the medicine. I personally don't like to give dosing amounts over the phone, especially if you wake me from sleep. It would be too easy to give the wrong amount, which could be dangerous for your child. It is safer for you to always learn your child's dose when you buy the medication.

Continued illness despite treatment 

Sometimes parents call because they're frustrated that their child is still sick after a few days. Typically these are Sunday evening calls because the parent wants to get back to work Monday. I can't fix this over the phone. See Evolution of Illness for more on how illnesses evolve over time.

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.

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!