Are you following your doctor's instructions?

Every day doctors assess and treat patients. Most doctors follow standard guideline practices or have good reason to not follow them for any individual patient. Insurance companies are taking it upon themselves to "help" doctors follow these guidelines. They review their records for certain diagnoses to see if proper testing and treatments are used by those patients.

While this can be helpful to nudge doctors who might not follow standard guidelines, it is annoying for those of us who try to. 

It is not uncommon for me to get a letter from an insurance company telling me that my patient is not being cared for properly. Usually it is because a child with a diagnosis of obesity has not had a lipid panel (cholesterol) drawn despite my ordering it months ago (or even multiple times with many reminders). Or a patient with asthma is not on a controller medicine or hasn't had an asthma check in 6 months.

The letter includes something like this (sorry for the poor focus):

picture from actual letter

These letters frustrate me because what am I supposed to do with them? I note it in the chart to discuss at the next visit and often have a nurse call for a parent to schedule a visit or go to the lab or pharmacy to get the tests or medications previously ordered, but typically it doesn't make a difference. Parents still do not follow through with recommendations.

Doctors are graded by insurance companies. We are supposed to follow guidelines to provide appropriate care in a cost -saving manner to the clients of the insurance company. Insurance companies can use the information they have about patient compliance (through coding and billing submitted by the doctor, the lab, the radiology facility, and the pharmacy) with standard guidelines to pay physicians various amounts (i.e. higher payments for "top notch" docs and lower payments for those who don't meet compliance standards) or they might simply stop allowing a doctor to be one of their providers. Remember it doesn't matter if a doctor orders a test or medication, only if those orders are completed. The insurance company only knows about the order if the code is submitted at the time the test is done or the medication is filled. They have no idea if the patient got samples in the office (therefore doesn't need to fill a script) or if the doctor gave a prescription, but the patient can't afford to pick it up or doesn't fill it for any number of other reasons.

Unless you were under a rock or never watch the news, you probably heard about the thousands of doctors recently removed from certain insurance panels. Some of this is probably unrelated to following the guidelines, but it is very possible that your favorite doctor might not be invited to participate in an insurance plan because enough of their patients do not get the recommended tests and treatments. Whether this is due to the physician not following guidelines or patients not following the doctor's recommendations does not matter. If a prescription is unfilled, the insurance company never knows it was written. If you fail complete the autism screen, do the lung function test, or go to the lab to have the labs drawn, the insurance company does not know they were recommended and ordered. If you do not follow up as requested by your doctor, the doctor gets dinged by the insurance company.

Part of the new healthcare laws includes that physicians must show follow up of referrals, completion of labs, and in general follow up on all orders.

Insurance is in a general state of uncertainty at this time. Pediatricians and other physicians around the country are nervous with all of the recent and upcoming changes. No one is certain how we will be paid. I know everyone thinks doctors are rich, but that is often not true and another discussion entirely. The truth is that any business needs an influx of cash to survive.

New high deductible plans mean that we will need to collect payment from patient families instead of the insurance company, which will likely decrease collections and increase the time to collect. This affects the bottom line. In October, a new coding and billing system is due to be implemented. Many experts expect that payments will be delayed by insurance companies for 3-6 months. What business can survive without any income for 3-6 months? New healthcare laws make it possible for patients to appear that they have active insurance, but if they haven't' paid their premium, the insurance company can refuse to pay. If insurance companies grade us on a "lower" quality scale or cut us from their panels, an office will bring in less income. All of these variables will make it more difficult for physician's offices to pay their bills (rent, insurance, staff salaries, purchase supplies, etc). Many private physicians are already selling out to big hospital or other medical systems. With this they lose control over their practice and become employees. I do not want to go that route.

What can you do to help insure that your favorite doctor's office stays in business?

• Schedule and keep appointments as recommended. This includes all routine well visits, follow up visits for chronic illnesses, and rechecks of acute illnesses as recommended. If you don't intend to do the recommended follow up, talk to your doctor about why.
• Know your insurance plan to estimate your medical costs. I know this is very difficult because there is little transparency in medical billing. What a doctor charges, what an insurance company has the doctor's office write off, what insurance pays, and what insurance requires the patient to pay is usually not clear. Believe me, I wish the system was different too, but we must work within the system until it changes. Take the time to ask the doctor's office about charges and call your insurance company ahead of time if there is question about your percentage of that charge.
• Pay bills on time. If you question a bill, call your doctor's billing office for an explanation. If you are unable to pay the full amount, call the billing office to set up a payment plan. Don't simply ignore a bill! It won't go away if you don't address it.
• If you disagree with a recommended lab, test, prescription, referral, or follow up: tell the doctor at that visit! Either we can change the recommendation and document in the chart why we are changing it, or we can discuss with you further why it is important. 
• If you cannot pay for the recommended lab, X-ray, or prescription, tell your doctor. We might have ideas of how to get help.

Bumps, ridges, and soft spots on baby's head

Parents often worry about lumps and bumps on a baby's head unnecessarily. Babies normally have ridges and soft spots on their head for a while after birth. Many have a type of swollen gland that parents can feel when rubbing the head.

All of this is normal.

Let's begin with a brief overview of a baby's head. We are born with many bones in our skull. This allows the head to be squeezed out of the birth canal as the boney plates move together or even overlap one another.

photo source: Shutterstock

Sometimes you don't really notice much with these bones, but other times they still overlap one another noticeably after birth. A baby might have a cone shaped head after birth, but this usually quickly reshapes into a round head over a couple days.

There are 1-2 "soft spots" at birth. Usually the one on top to the head (the anterior fontanelle) remains open enough to feel for the first 18-24 months of life. The one towards the back of the head (the posterior fontanelle) is unable to be felt by about 2 months of age. Many parents fear that touching the soft spot will somehow damage the baby's brain. Normal touching won't hurt, even from a 2 year old sibling. There are several layers of skin and other tissues protecting the brain. Doctors will feel the soft spots during routine check ups to be sure they are the right size for the growth of the baby's head. (There's a lot of variation here, so if you question the size of your baby's soft spot, discuss it at a visit with the doctor. He or she will need to not only feel the soft spot, but also will look at overall head growth, baby's development, and the shape of the head.)

Coming out of the birth canal can be traumatic for both mother and baby (and often for fathers too). Sometimes babies have a big soft or squishy bump on one side of the head, which usually is essentially a large bruise. The two most common causes for this are cephalohematoma and caput saccedaneum. A cephalohematoma develops when there is bleeding between the skull and the bone lining called periosteum. Since it is outside the skull, it doesn't affect the baby's brain. It covers only one of the bones, and never crosses one of the suture lines. A caput is from bleeding one layer above the periosteum in the skin. It can cross the bone areas since it's not limited by the lining of the bone (periosteum).  Both of these conditions can lead to increased risk of yellow jaundice due to breakdown of the blood collections, but usually self resolve without complications. If baby seems uncomfortable due to this area, discuss with your hospital nurse or doctor.

This picture attempts to show the layers of bleeding described here and includes more uncommon (and more concerning) types of bleeding.

photo source: http://en.wikipedia.org/wiki/File:Scalp_hematomas.jpg

Flat spots are common, especially if babies prefer to always look to one side. This can cause the forehead to seem to bulge on one side or an ear to appear closer to the face than the other ear. This is usually due to baby laying one direction most of the time, allowing the brain to grow all directions but spot baby is laying on. It is important to get baby to lay looking right sometimes, left other times. Supervised tummy time is helpful too. (I recommend starting tummy time day one. The earlier you start tummy time the less they seem to hate it!) When you hold and feed baby, alternate arms because they will look toward you and by simply holding in the right arm sometimes, left arm other times, they will turn their head. If your baby resists turning his head, check out this Torticollis information.

One of the most common head worries that brings parents to the office is a pea-sized (or bigger) movable bump on the back of baby's (or even an older child's) head. This is usually an occipital lymph node. When I say it's just a lymph node, some parents automatically worry about lymphoma. Don't go there. Most of us remember having a swollen lymph node (AKA swollen gland) under our jaw or in our neck when we are sick. When they develop on the back of the head, it is usually from something irritating the scalp, like a scalp probe during labor, cradle cap, or bug bites in older kids. They can remain large for quite a while (often seeming to come and go when kids have scalp irritations), but unless they hurt to touch, enlarge rapidly, are red and hot, or a child looks sick otherwise, I don't worry about them.

photo source: Shutterstock

In short, most lumps and bumps on your baby's head are normal. If you're worried, bring your baby in to have your pediatrician look and feel.

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Challenges to remain a financially stable medical practice

I recently posted Top 10 challenges facing physicians in 2014 and was pleasantly surprised to see that it was one of the more clicked-on posts that day. Business Facebook pages allow administrators to see  total reach (yellow), post clicks (blue), likes/shares (pink). (The post with the overall largest was of course a cartoon of the hazards of shopping at Target... cartoons and memes are always popular.)

Why was I pleasantly surprised? Because I want people to know more about insurance issues and our office financial concerns. I don't know if people made it through the entire 10 concerns, so thought I'd summarize them.

Why do I want to spend time blogging about this?

I fear that people presume we will always be there for them, but historically bills often aren't paid by families for various reasons. In the past we at least collected from the insurance company and a smaller percentage was patient responsibility. With the higher number of high deductible plans this year, we are at serious risk of not collecting payments or having delayed collection of payments at a time that our practice is forced to spend significant money on government mandated things. We will be implementing new billing policies soon to help protect the financial stability of our office. I know we will hear complaints because no one wants to think about money when they are worried about the health of their child, but the reality is we need to implement these changes so that we can continue to be around to take care of your children. If I could have a wish granted, I would ask that all money is paid to insurance companies, from the policy charge for the insurance itself (like we pay now, often with the help of our employer) to the money owed to the physician or hospital for services rendered. This would allow doctors and other medical professionals to stay out of the money game. I hate having the money conversations when parents think they shouldn't have to pay something. We submit a bill for services rendered to the insurance company and the insurance company ultimately decides what the patient family owes, based on your contract with them. If we don't then bill you that amount, it is a contract violation on our part. If you don't pay that full amount (that may have already been discounted by your insurance company) you are violating your contract with them. The system is not good because we bill something that is due based on your contract with a third party. It would make sense if they had to collect all the money and they paid all the bills. That is my dream...

But I'm getting off track. I want to summarize the very long article referenced above and point out how it affects our office. You will find that many of their points interlink with each other, which seems redundant, but they are so intertwined, it is hard to separate them out.

1. Payment for medical services. Payment structures are moving more toward an outcome based system. If our patients get quality care and we can prove it with metrics, we will be payed at a higher scale. While in theory this is good, it is really hard for physicians to prove that they do good care. It takes staff time and money to run reports. And we have no ability to make patients follow recommended care. A popular metric to measure is asthma, since it is a common pediatric condition. I get insurance warnings routinely that a patient isn't filling preventative medications on schedule. Sometimes that is because they are using it as told because of overall good control and my desire to use as little medicine as needed for good control, but that is less than the twice/day general recommendation. Unfortunately, sometimes it is because the co pay for the medicine is too much and the family uses it less than needed because they can't afford it.  With new plans that have higher deductibles, I see that more often. I can direct patient families to programs that help with drug costs, but I can't buy their medicine for them. When they end up suffering with more asthma symptoms, they use ER and office visits for sick visits, and then I'm dinged by that same insurance company that set their rates too high for families to afford the best medicine.
2. Government mandates. This year the coding and billing system that has been around for years is completely changing. This means that the computer systems on our end need to be updated and the computer systems on the insurance company end need to be updated. We will be required to use the new system, ICD 10, starting October 1st, but surveys are showing that it is very likely that insurance companies won't be able to accept those codes yet. This will delay processing of all bills submitted. Various experts say that payments may be delayed 3-6 months. How can any business survive if they make no money for that time? Not to mention the conversion costs to our practice. Estimates range from $83,000 to $2.7 million. Our practice is mid-sized, so will probably be somewhere in the middle of that. Where will this money come from? We are fortunate that we started using electronic health records (EHR) many years ago. That was a huge financial cost at the time, but I am glad we don't have to have that added expense now. (I'm not sure if EHRs will directly be required, but they certainly make it easier to meet all the other requirements now mandated.)
3. Payer headaches, and the fine print. Physicians are being dropped from insurance panels at a time when there are more insured patients. This will make access even more difficult. Insurance companies are requiring more prior authorizations than ever for tests and treatments. This takes staff and physician time. That time is not reimbursed by the insurance company. 
4. Time. I love to spend time with my patients, but with all these numbers adding up, I might have to schedule more visits per hour so that I can pay our office bills at the end of the month. This means less time with each patient. I don't know how that can be done and still provide good care, so altering my schedule will be one of the last changes I want to implement. 
5. Technology costs. Many practices starting a new EHR will not be able to see the same patient volume due to the added time documenting in a new charting system. As I mentioned before, I am thankful that we took that plunge and ate those costs years ago. But we still have IT costs on a regular basis and are looking forward to more this year with all the changes, both described elsewhere here and things like Microsoft is no longer supporting the version of Office that we were on, so we have to upgrade. This upgrade is not as simple as it sounds because it alters the way our EHR interacts with it and some of our computers are older and must be replaced to support the new software.
6. Staffing and training. We have been moving up the ladder in Patient-Centered-Medical-Home certification. Several staff members have put in significant time over the last few years building and implementing new practice policies and generating and reviewing reports. Our EHR has not always been able to generate the needed reports, so we had to find a company that could use data from our EHR to build them. Several times that we almost meet a metric, they update the rules, meaning new reports need to be generated. It has been a frustrating process, to say the least. I find that most of the things they want us to prove we were doing already, it's just that proving those things can be difficult. We are fortunate that we have a very low staff turnover rate. I hope all of our employees know how much we appreciate them!!!
7. Putting control back in the hands of physicians. Physicians generally go into healthcare to help others, but with all the stresses described here, many are dissatisfied on the job. Some are leaving patient care and finding other employment. Some still practice, but their dissatisfaction probably impacts the care they give. Many are fearful of all these stressors and leave private practice to be an employed physician. I have friends who used to love their doctor, but now can't get the access they used to have because of the bureaucracy of the new office management. Our local children's hospital has wonderful physicians, but I hear complaints often about the problems with access and other business themes. If these same physicians were self employed, they would be able to control these problems more easily on a smaller scale. As more physicians become employed, I think these problems will magnify.
8. Changing patient populations. More patients are opting for high deductible plans, meaning payment must first come from patients. This means the regular income physicians get from insurance companies won't happen until patients meet their deductibles. Most patients hope to never reach their deductibles. Now we will be relying on patients to pay their bills in a timely fashion. I personally hate talking money with patients. I want to provide the care that is recommended. While I think that having patients invested in their healthcare can make them more informed consumers and has the potential to help them make better healthcare decisions, it can also be a roadblock to good care. There is also the problem that I can't easily tell a parent how much it will cost. We can tell them what we bill, but their insurance will probably discount it. It might be covered in full by the insurance company and not cost the patient a dime. I don't know the patient's insurance payment requirements, and finding out information from the insurance company is difficult. We can provide the code so the parent can call the insurance company and ask, but at the time of service there simply isn't time to spend on hold with the insurance company to find out before the visit is over. Some parents have smartly called us ahead of time to ask what will be billed, but our staff can't know exactly what the physician will order at any visit. They can make best guesses based on the type of visit, such as an 18 month old well visit will have standard physical, vaccines, and autism screening. But if the child is tugging at an ear and there is wax obstructing the ear drum, we will remove the wax and diagnose either ear pain or ear infection plus impacted ear wax. None of that could have been anticipated based on the well visit scheduled. (Adding separate visits to a well visit is another topic entirely, since the well visit is often covered entirely by insurance, but the ear issue would be separate and fall to patient responsibility.) Using asthma again as an example (but it also goes for autism screenings, cholesterol screenings and more): I don't want to skip the spirometry for my asthmatic patient because the parent doesn't want to pay for it. That means I won't meet the metrics for asthma care, which puts me at a lower pay scale because I'm not a "quality" doctor. And more importantly, I'm not doing what I know is best for the patient's asthma management. How can I ethically treat patients with the standard of care I believe in only if they can afford to pay it? Should I lower the standards if they want to cut corners? That is a slippery slope I don't want to travel!
9. Primary care's changing role. Primary care physicians are going to be more accountable for being the central member of the health care team. As part of the Patient Centered Medical Home, we will continue to offer full scale preventative healthcare as well as management of most illnesses. We are also required to follow up to be sure patients got into the specialist we referred them to, or that they did the labs as ordered. We must have easy access for same day visits and extended hours. We must show that we follow practice guidelines. Although my practice already does these things, we must prove that we do, which takes even more uncompensated staff time.
10. Work life balance. This has always been a tricky thing for physicians. We cannot expect to work a 40 hour work week unless we are employed and there are shifts without any call requirements and all charting, follow up phone calls, review of labs, etc can be done while on the clock. Those of us who also own a practice must do business things when we aren't seeing patients. Either we cut our productivity and do business during business hours, or we see patients during business hours and do other business things after hours. This cuts into our family time. But we must be able to pay the bills... This explains the high rate of physician dissatisfaction and burnout. Physicians have a higher suicide rate than the general population-- up to 4 times the general population for male physicians by some estimates. This rate cannot support a healthy healthcare system, and with all the added issues with the 2014 changes, more burnout or sell out is to be expected.

In summary, there are many things that worry me and other physicians about our current healthcare climate. I still love my job, at least the parts where I get to take care of patients to improve their health and well being. I just wish we didn't have to worry about how to keep our office financially viable. Any time money comes into the equation, it can impact healthcare. I hope that all these changes help people take charge of their own health in new ways and that they can find ways to pay for all their healthcare needs. I also hope that all the regulations really do improve healthcare outcomes and help physicians provide better care, not just more documentation of care.

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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.

home alone

Parents often wonder when it's okay to let their kids stay home alone. There is no easy answer to this question. Kansas does not have a specific age by law, but the Department for Children and Families suggests that children under 6 years never be left alone, children 6-9 years should only be alone for short periods if they are mature enough, and children over 10 years may be left alone if they are mature enough. (For state specific rules, check your state's Child Protection Services agency.)

photo source: Shutterstock

Staying home alone is an important part of growing up. If a child is supervised at all times throughout childhood and the teen years, he won't be able to move out on his own. (This might be the case if there is a developmental delay or behavioral problems that make it not safe for that person to be alone.) The age at which kids are able to be alone varies on the child and the situation. Parents must take many things into account when considering leaving a child alone.

• Maturity of the child. Do they know what to do if someone knocks at the door? Can they prepare a simple meal? Will they follow general safety rules, such as not wrestling with a sibling or jumping on the trampoline unsupervised? Will your child be scared alone? Do they know how to call you (or 911) in case of problems or a true emergency? Do they understand activities that are dangerous and need to be avoided when unsupervised?
• Readiness. Is your child asking for the privilege of being left alone or are they afraid to be alone? Forcing a child who is afraid to stay alone can be very damaging. Only allow kids to stay alone if they want to and are capable of the responsibility.
• Behavior. Some kids are typically rule followers. Others are not. If your child has problems following rules while supervised, he is not ready to be left alone. Dangers are more likely to come if kids are risk takers and cannot control their behaviors. House fires, hurt pets, physical fights among siblings, kids wandering the neighborhood, and online behaviors that put kids at risk are but a few ways kids who don't follow rules can get hurt. Even if kids used to be able to be unsupervised, things change. If you think a child or teen is depressed or is using drugs or there are other concerns, it might not be safe any longer to leave a person unsupervised.
• Number of children and their ages. Kids can supervise younger siblings as long as they are mature enough and the dynamics between the two allow for it. Two kids of similar ages can keep each other company if they are able to be responsible alone and not fight. Some children can stay alone, but are not yet ready to take care of younger siblings. If they can do it when parents are home, they might be ready for unsupervised babysitting. In Kansas kids must be 11 years of age to watch non-siblings, but there is no law for siblings. Leaving an 11 year old alone with a 0-2 year old is much different than with a school aged child! You must know your kids and their limitations.
• Left alone or coming home to an empty house? If you leave kids home, you can first be sure doors are locked and kids are prepared. If they will be coming home to an empty house (such as after school), there are a few more things to consider. Will they be responsible to keep a house key? Is there an alternate way in (such as a garage code)? Do they know how to turn off the house alarm if needed? How will you know they made it home safely? 
• Pets. If there are pets in the home, is your child responsible to help care for them? Can they let the dog out? Can they take the dog for a walk? Do they have to remember to feed the pets? Does your pet have a good nature around the kids?
• Neighborhood. Where you live makes a difference. Do you live on a quiet cul-de-sac or a busy street? In a single family home or an apartment building? Do you have a trusted neighbor that your child can call in case of emergency? Is there a neighbor that your child seems to be afraid of? Are there troublemaker kids down the street? Do all the kids play outside after school with a stay at home mom supervising? (If you will allow your child to go out expecting that the other parent will be there, be sure to talk with that other parent first to be sure it is okay -- the parent might not want that responsibility.) If you don't know neighbors what can your child do if there is a problem? Is your child allowed to go outside when you're not home and under what conditions (with a group of kids, with your big dog, on foot only or on a bike, daylight/dark, etc)? If they can go outside who do they tell where they are going and when they will return? Are there area limitations of where they can go? Run through scenarios of what to do if someone they don't know (or feel comfortable with) tries to talk to them. 
• Gradual increases in time alone are helpful. You can start by doing things in the home where you tell kids you don't want to be disturbed for 30 minutes unless there's an emergency. Let them know it is practice for staying home alone to show responsibility. When they do well with that, try going to a neighbor's house briefly. When they're ready, make a quick run to the store. Gradually make the time away a bit longer. 
• Time of day. Start with trips during daylight hours when they don't need to make any meals. Only leave kids alone when dark outside if they are not scared and they know what to do if the power goes out (i.e. flashlights, not candles). Overnight stays alone are generally not recommended except for the very mature older teen. And then you must think about parties or dates visiting...
• List of important things. Make sure kids have a list of important phone numbers. They should have an idea of where you are and when you'll be back. What should they do if they have a problem? List expectations of what should be done before you get back home. 
• Are there any no's? While it is impossible to list every thing your child should not do when you're not home, make sure they know ones that are important to you. Having general house rules that are followed are helpful to avoid the "I didn't know I couldn't..." Think about how much screen time they can have, internet use, going outside, cooking, etc. Are they allowed to have friends over? Can they go to a friend's house if their parents are home? What if those parents aren't home? Some kids might be ready for unsupervised time at these activities, others not.
• Emergencies. Go over specifics of what to do if ... (fire, electricity goes out, someone calls the house, a friend wants to come over, they are hungry, there's a storm outside, they spill food or drink, there's a package to be delivered, etc). Quiz them on these type of topics. Do they know what the tornado alarm sounds like and what to do if it goes off? (Do they know the testing times so they aren't afraid unnecessarily?) Can they do simple first aid in case of injuries? Discuss the types of things they can call you about-- if they call several times during a short stay alone, they aren't ready!
• Supervise from afar. When kids are first home alone, you can call to check in on them frequently. Tell a trusted neighbor that you will be starting to leave your child home alone and ask if it is okay for kids to call them if needed. Ask how things went while you were gone. Did any problems arise? What can be done to prevent those next time?
• Internet. This probably deserves several posts on its own since there are so many risks inherit to kids online. Be sure you know how to set parental controls if your kids have internet access. Review all devices (computers, smart phones, tablets, etc) for sites visited on a regular basis. Talk to your kids about what to do if they land on a site that scares them or if someone they don't know tries to chat or play with them online. Be sure they know to never give personal information (including school name, team name, game location and time, etc) to anyone on line. If they play games online, remind them to only play with people they know in real life. If they upload pictures and videos, can the location be tracked through GPS? For more on internet safety, check out Yoursphere.
• For more on staying home alone, see MissingKids.com.

What does plumbing have to do with pediatrics?

This post has nothing to do with pediatrics, yet everything to do with how the process of medicine is like plumbing.

photo source: Shutterstock

We have lived in our house about 15 years. Shortly after we moved in I suspected a leak behind our  shower wall. The floorboard in the bathroom was molded and the drywall above it warped. The tile would be dry, but the grout one tile out would get wet -- so it seemed unlikely the shower door wasn't closed properly. We had a plumber evaluate it but he didn't find anything amiss. I think he thought I was crazy.

Years went by and I still thought there were issues every once in awhile, but irregularly enough that I wasn't concerned to do anything about it. My engineer husband didn't seem too concerned. I think he also assumed we were being careless in the shower and allowing the door to leak.

We had another plumber look at it about 5 years ago when we were updating our bathroom. He confirmed that there is no leak, fixed the drywall, and replaced the floorboard. He bragged that our new caulking shouldn't mold due to a special something they put in it that makes it mold resistant.

I still had my suspicions, but what do I know? I'm not a plumber.

The new floorboard is again moldy. The new caulk seems to get moldy from behind -- I clean the outside very carefully and it only looks discolored from behind. It has started to crack, so I thought maybe the water gets trapped behind and allows it to mold.

Over the summer I was cleaning out my daughter's closet. We decided to remove a bookcase that was there. The carpet underneath was completely moldy. Since her closet abuts our shower, this confirmed my leaky pipe suspicion despite two qualified plumbers saying they are fine. (My daughter had a blast breaking down the bookcase so we could dispose of it!)

Recently I dumped a bucket of water after mopping into the bathtub that never gets used in the same bathroom. (I usually dump mop water into the kitchen sink.) When I moved on to clean the shower, I saw something unusual: there was dirty water seeping from behind the caulking and dripping into the shower. No one had showered yet that day. I brought my husband up to show him. I was convinced that the tub leaked. That would explain the intermittent nature of the problem! He said it's not possible for the water to go uphill and into the shower caulking above the base rim.

Hmmm....

It's been 15 years and it can't be a bad leak since the floor hasn't completely rotted out. We only see signs of water leakage intermittently. We know it will be an expensive repair, so we are saving up and waiting... a few more months won't matter, will it? And two plumbers have looked for a leak without success. I'm closely monitoring to see if I find a pattern to help find the leak when we open up the wall.

We still have several theories going on with pipe and roof leaks being the top two. But no definitive answer.

So. What does this have to do with medicine?

It parallels complex diagnoses. Most people are not informed consumers when it comes to how their body works. I'm not saying patients are not smart. I'm a well educated person, but I know nothing about plumbing. I am an uninformed consumer. My husband is an engineer, so has a little knowledge of how our house is put together, but it's just enough to give him false confidence. He has been in denial of a problem for most of the 15 years we have lived here. Two qualified plumbers failed to see a problem, despite my concerns. I didn't follow through on suspicions based on their expertise and recommendations.

Physicians spend many years learning anatomy, physiology, pharmacology, and more. Years more are spent fine tuning diagnostic processes with actual patients. We continually learn throughout our careers based on new research and experiences. Despite all this training, one physician can't know everything and sometimes must refer to a sub specialist to sort things out. And I know they sometimes don't figure it out. We all can't be the genius doc from House, who seems to figure out every obscure diagnosis in one short hour.

What does that mean for patients?

If you think there is a problem, be as specific as you can with your symptoms. This is really hard when kids are the patient. They often can't describe what they are feeling in significant detail. Write down any possible associations that you can come up with and have your physician review the list with you. If your physician doesn't come up with a source or diagnosis, keep asking questions if you are still worried. (Don't take 15 years to sort things out with a human body!) If you don't find answers despite persistence of symptoms, ask for a second opinion.

Sometimes what worries parents and patients really is nothing to worry about. Maybe it's a common issue that needs no treatment (like a newborn rash or intoeing). Maybe what you're already doing is the best known treatment there is. Depending on the severity and duration of symptoms, more or less might need to be done. I'm not advocating for the multi-million dollar workup for every symptom, but if you think something's wrong, be sure to talk to your doctor about it! Make sure they hear your concerns and if they don't have an explanation for things, ask more questions to find answers.

Sleep tricks

I preach about sleep to kids all the time, both at the office and at home. It is one of my three most important things for overall health along with eating nutritious foods and exercise. Most of us don't get enough sleep. Here are some tricks to get in a few extra minutes each day... they all add up!

photo source: Shutterstock

Most of these tips are appropriate not only for kids and teens, but also for their parents!

Know how much sleep is typical for every age group. A great infographic of this is found at the Sleep Foundation. Warning: It shows generalizations. For example: when tweens and teens go through a growth spurt many need 10-11 hours of sleep per night, which is more than the graph shows. Just remember that individuals are just that: individual.

Think of sleep as a currency. We can go into sleep debt when we don't get enough. If it's just a little loss of sleep, it is easy to catch up and pay back the debt. The further into debt you go, the harder it is to get out of debt. Don't let the bank come after you in terms of health problems!

• Listen to your body. If you're tired, you need more sleep. The longer you stay up, the harder it will be to fall asleep. It is ironic, but sleep deprivation leads to insomnia. If you suffer, try to get extra zzz's on a weekend to fill the deficit. But don't allow yourself to sleep so late that you can't go to bed on time that night. (Note: many kids get hyper when they're tired, so don't be fooled if they have lots of energy in the evening. If they don't wake easily in the morning, they are tired!)
• Routines. Go to bed and get up at the same times every night. If you stay up later on a weekend, be sure it isn't more than 2 hours past your ideal bedtime.
• If you have a hard time getting up, try to get natural sunlight as soon as possible in the morning. It helps set your circadian rhythm. If you can't get natural sunlight, turn on lights in your home.
• Conversely, start turning down lights a few hours before bedtime. Avoid screens (tv, computers, smart phones). Lights keep you from feeling tired. Don't let them keep you up!
• Journal before bed if thoughts keep you awake. People who spend bedtime thinking about everything can't sleep. Jot a few things down to give yourself permission to not think anymore. Sounds weird, but this "worry list" works for many people!
• Be active during the day. Lounging around makes you feel more tired during the day, but it is then harder to fall to sleep at night. Experts recommend avoiding exercise for a few hours before bedtime, but I know that is really hard for kids in sports. I don't have a great fix for that, unfortunately.
• Set the alarm for the last possible minute. Kids and their parents who hit snooze several times miss out on all that sleep that they are in a half awake zone. If you really don't need to get up until the 3rd snooze time, set the alarm for that time. You will be more well rested so it will be easier to get up immediately. Train your body (or your kids) to get up at that time. After several days of an extra few minutes of sleep, you'll notice the difference!
• Learn meditation or biofeedback. Some insurance plans might pay for this. There are apps available for smartphones and tablets, just do a search. Here's one review of apps to release tension. I have used the StressEraser, but it can be pricey. Searching Amazon or eBay will have less expensive options, allow you to browse several brands, and read customer reviews.
• Set the mood in the room: darken the room, get the temperature "just right", and find the number of blankets that helps you sleep. Setting up a fan or other white noise maker helps many people sleep. For more tips on setting up the perfect room for sleeping, see Bedroom.
• Keep kids out of the parent bed so everyone gets the best sleep. Snoring, different bedtime, and other body movements makes it hard to sleep together. No one sleeps well, which makes everyone grumpy the next day. 
• Reading at bedtime can be a great relaxing thing, but if you have a page turner, be careful to not get caught up in the book for hours. I find that stopping at a lull mid-chapter is better than waiting until the end of a chapter. A good author leaves you hanging at the end of a chapter and begging for more! Set a time limit and stop reading when time's up! That's what bookmarks are for.
• Avoid caffeine, especially hidden sources. I have occasionally gotten ice cream with coffee for a family bedtime treat, only to find out upon tasting it that it had coffee. Caffeine is often added to drinks, so read labels. But be careful! It might not say caffeine directly. Some are labeled as "guarana" -- a plant with caffeine. Pretty much anything that is labeled as an energy drink (or food) is a likely culprit.  Even decaf coffee has a small amount. Chocolate naturally has caffeine... the darker the chocolate the higher the caffeine content. Some pain relievers and other medicines have caffeine. Especially for those not accustomed to caffeine, it will disrupt sleep even if taken several hours before bedtime.
• Take a warm bath. This can help relax you for a good night's rest.
• Ask a family member to give you a massage or back rub. Again, a great way to relax!
• Warm milk or herbal teas might help some sleep.