Can I talk to you privately?

Every once in a while a parent will tell the nurse that they want the child out of the room to discuss an issue with the doctor privately. This is usually something they perceive as a negative thing for the child to hear. Some of the most common concerns are about the child’s weight or behaviors. Sometimes it relates to a change in the family dynamics, such as divorce or a parent having a significant illness.

Secrets should never be kept…

While I understand the parent’s intentions, I find this to be disruptive and counter productive. As much as I try to find an excuse to have a child leave, it is usually obvious that the nurse keeps them out longer than needed.

If we have the child leave the room, he knows something is up. We are talking about him.

But not sharing with him.

What could possibly be so bad that we won’t talk to him about it?

How do you feel when you suspect people are talking about you?

When people talk secretively it hurts.
When people talk secretively it hurts.
And we should always live by example.

I teach kids from early on that there should be no secrets in families.

Why then should parents and doctors keep things from the child?

That doesn’t mean kids need to know everything.

We all know that as adults that we do shield our kids from things.

Kids do not need to know our financial worries. We can teach them financial responsibility without increasing their anxieties.

They do not need the burden of knowing about extramarital affairs. If there are problems in a relationship, they will know there are problems, but they do not need to know details.

I don’t think that kids need to know everything, but that doesn’t mean that we should make it obvious that we’re hiding something. Especially when it pertains to them.

What does the child know?

Any patient needs to know what the issues are so they can be addressed. This includes most kids.

My guess is most of these kids already know what the concerns are.

They may need help working on the concern or help adjusting to the home life situation.

If they are overweight, we need to talk about what they eat, how they exercise, and how they sleep.

When there are behavior problems, they need to give insight into how they feel and what leads to the behaviors.

Regardless of the issue, they need to be a part of the plan to fix the problems. If they aren’t on board, they won’t change their habits. I can talk about weight (or behavior, or drugs, or whatever the concern is) sensitively and in an age appropriate manner with the child. The kids at school are likely talking about it in a not-so-sensitive manner, so it’s best to not make it worse by secretly discussing it.

What if it really needs to be said?

If a parent really wants to let a physician know specific points without the child present, there are ways to do that without making the child feel left out.

  • Send in a letter or secure electronic message with your concerns before the appointment. Be sure it’s at least a few days before the appointment so the doctor has a chance to review it!
  • Schedule a consult appointment for just parents to come in without the child.
  • Call in advance to note your concerns so the physician can address it as needed during the visit.
  • Slip a note in with all the paperwork you’re turning in during check in so the physician can read it before coming into the room. Be sure whoever you give it to realizes it’s included with the standard paperwork so they can pass it on.
  • Don’t bring siblings to an appointment where you want to discuss a private matter with your child.
All of these help the physician know your concerns without blatantly kicking a child out to talk about something privately.

Your child will appreciate it.

Help Us Help You! Make the most out of phone calls

Hello.  This is Dr. Stuppy.  I’m returning your call about…

That’s how my phone calls start, then they take various turns. Some are easy, some not so easy. I’d like to discuss what makes a phone call to the doctor’s office more productive, so we can help you better.

All examples are entirely fictitious, made up of 18 + years of phone call experiences.

Many calls start off like this:

Hi. This is Mary Sue. My son has a rash and I want to know what to do.

Me: ?????

I must ask many questions for more information.

Some callers don’t seem to know what to say, so they only answer direct questions.  How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this?

On and on…

Other calls start like this:

Hi.  Thanks for calling back. My son Jack is 3 years old. Well, really his birthday isn’t until next month, but he’s almost 3. He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn’t acting funny or sick that first day he felt warm so I didn’t check his temperature. He actually was fussy last week, but I don’t think he ever had a fever then. I was thinking maybe he didn’t sleep well last week, but I don’t know why. His temperature was 100.3, that was on Tuesday around 7am. I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7….

My thoughts so far: Get to the point.

Sorry, but that’s true. I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever). I don’t even know what the parent’s main concern is.

just the facts, MA’AM.

When parents call, they need to summarize with pertinent facts. While they shouldn’t leave out important helpful information, they don’t need to mention every time they took a temperature.

Much like the evening news: they can’t do a play by play of every football game. There’s no time and it serves no purpose. A few highlights of the game and the score. That works well. People get a pretty good idea of how the game went.

It’s the same thing with phone calls to your doctor’s office or on call provider.  We have thousands of patients. Not all call, but during peak cold and flu season, there are many calls all day and night. The phone nurse or on call provider simply can’t spend 15 minutes chatting about every detail. That’s for your friend and you to discuss over coffee.

During the cold and flu season, it’s not uncommon for me to be on the phone with one parent when another call comes in. This is at the same time I’m trying get groceries or do other things I need to do for my family on evenings and weekends. (Being on call after hours doesn’t mean that I don’t have to work during the day.) I really don’t want to sit and chat. I don’t have time for play by play action. Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise. 

Things that help us help you:

Know what’s going on.

When a parent calls and the child is at daycare or grandma’s so the caller doesn’t know details, we can’t really help. Yes, parents have called for advice when they’re on their way to daycare but don’t know any more than the child has to be picked up due to a symptom such as vomiting, fever or pink eye.

See your child first or have the person with the child call us. When you pick up the child, ask for details of their day. Learn how they ate/drank, how they acted, etc.

Sometimes you’ve been up several nights in a row with a sick child and things get jumbled in your head. It happens.

Write down the pertinent facts to get them straight if you need to.

Start with your child’s full name and birth date.

I can’t tell you how often parents jump right into their worries without stating who their child is. This is important not only for chart documentation of the call but also so we know how old your child is.

Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.

Give pertinent facts related to the concern.

If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.

If you have given a fever reducer, share that.

Find a quiet place to talk.

When my kids were little they always wanted to be held when they were sick. I get it.

If you’re on the phone and they’re crying in your arms, it’s very hard to have a conversation.

Please find a safe place for your child to rest while we talk if possible.

If they won’t leave you or stay quiet, have another adult talk to us after they’ve been briefed about all the symptoms.

Summarize symptoms and treatments.

Briefly describe symptoms and what you have done to help them as well as how your child responded to the treatment.

Mention All treatments

If you use a vaporizer or saline for a cold, or have stopped dairy and used gatorade for vomiting, let us know. If you use a traditional home remedy, please let us know.

Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.

Signs and symptoms can be tricky to describe

When there’s a rash, it’s typically best for us to see it, but if you call about a rash describe it in terms of location, color, and size. Many find it helpful to relate to common objects, such as quarter-sized.

Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.

Summarize, don’t tell a novel

Leave out details that don’t help. Trends and generalizations work well.

If we want more details, we can always ask.

Avoid words that could be interpreted other ways, use facts.

Commonly misused words are “lethargic” and “fever.”

Lethargy in a medical sense is ominous. Many parents use it when their child is only mildly ill and tired. Describe what you’re seeing instead. Saying “Johnny won’t even wake enough to drink or hold his cup,” gives me the thought he is lethargic. Saying “Johnny wants to sit on my lap and read books instead of playing with his sister,” shows that he’s not well, but definitely not lethargic.

Fever is a temperature over 100.4 F. Many parents use the word fever if their child feels warm to touch. It’s more clear if you state that they’re warm to touch or what the thermometer says and how you took it.

Dr. Christina has a great blog discussing commonly used terms that can be confusing to your physician and alternative word choices.

Examples of good call starters:

Start with name, birth date, summary

I’m calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours. He also has sore throat and headache. He’s drinking well but not eating much for 3 days.

I know this child’s name, age, pattern of fever and associated symptoms. The only thing I need now is the parent’s concern – so far they’ve been doing everything right. What made them call today? What’s their question?

Describe

Sally Smith, birth date 9.12.17, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn’t had a wet diaper in 12 hours. There’s no fever but she looks tired and it is hard to wake her to drink. She doesn’t have diarrhea. Her older brother had the stomach flu a few days ago but is now better.

Again, I know the child’s name and age and main problem – especially the fact that she sounds dehydrated. The parent didn’t use this word, but described dehydration (no wet diaper in 12 hours and it’s hard to wake her to drink). 

Include pertinent history

John Smith, birth date 9.12.17, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn’t have a fever, but I’m really worried.

Here I know the child’s age and that he was significantly premature – a big risk factor. He’s distressed because he can’t feed. Note: I made this baby not have a fever on purpose. He’s sick even without a fever. 

Getting More Information

Knowing where to get reliable information is important. There’s a lot of bad advice online. Fancy websites aren’t always reliable.

Sites I recommend:

The AAP has many resources on HealthyChildren.

KidsHealth is another great resource.

My office’s website, PediatricPartnersKC, also has many pearls of wisdom. Often when we give advice it’s already stated on our site. Parents sometimes call multiple times because they can’t remember what we said. This is frustrating on both ends of the phone. We wrote it down and made it easily available for a reason. Use our site! (For patients in other practices, check out your own pediatrician’s site.)

Things that cannot be done by on call providers – at least not well:

Prior authorization for an ER or urgent care visit that is already done.

Prior authorizations are not usually needed, but if they are required, we should talk to you to be sure the visit is necessary before you go.

If I didn’t send you to the ER, I can’t fill out paperwork saying I did. That’s lying and using my license inappropriately. Often I would have chosen another location or given home care instructions to get you through the night.

Of course if you do talk to me (or one of my partners) overnight and we do send you to an urgent care or ER, we are happy to fill out forms if needed by insurance.

“Allow” you to leave a busy ER.

It sounds silly, but I have had many calls from the waiting room at ER/Urgent Cares with parents asking if I think it okay that they leave due to a long wait. If you thought it necessary to go in the first place, I would be open to a malpractice lawsuit if I told you to go home without being seen.

You should ask their triage nurse who can make that assessment.

Refill medications.

I typically expect that your child is seen prior to most prescription refills for best medical care. If it’s urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern.

There are exceptions to every rule, but don’t be upset if the on call provider or phone nurse refuses to call out a prescription.

This is in the best interest of your child, not to be difficult. It’s easier to just call in the script than it is to argue this point, believe me. But easier isn’t better care, and that’s what’s important.

Make a diagnosis.

We cannot see the ear, listen to the lungs, or feel the belly over the phone. A physical exam and sometimes labs or radiology studies are needed to make a diagnosis. If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they’re not doing the best of care.

An example of a poor diagnosis by phone:

Just this week another child was seen in my office for a sore throat that wasn’t better on the amoxicillin prescribed by a telemedicine doctor through their insurance company. The exam clearly showed blisters on the child’s throat. The sore throat was from these blisters, which are from a virus, not a bacteria.

The antibiotic was never needed. In this case the child simply didn’t get better as expected with a presumed case of Strep throat, but fortunately she didn’t get diarrhea or have an allergic reaction to the antibiotic. Who knows if this contributed to more bacterial resistance and superbugs?

Not only did the family waste money on an unnecessary treatment, they also exposed their child to a treatment that could have caused harm.

I worry with the increasing use of telehealth that we will see more problems related to improper diagnoses and delay of proper diagnoses – some of which could be significant.

Swallowed poisons or medicine / drug overdose.

The United States has a great poison control system. They can give rapid advice that most doctors don’t have easily available.

Call (800) 222-1222 if you suspect your child has ingested something. PUT THIS NUMBER IN YOUR PHONE RIGHT NOW.

A visit’s better than a phone call for:  

Difficulty breathing.

If a child is having difficulty breathing and you don’t have treatments at home that work, he needs to be seen as soon as possible.

Dehydration.

An infant who hasn’t urinated in 6-8 hours or an older child who hasn’t urinated in 12 hours might be dehydrated and should be seen as soon as possible.

Some fevers.

Temperature above 100.4 F in an infant under 3 months or in an under immunized child can be serious and should be seen as soon as possible.

Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.

Fevers are scary and can make kids miserable. There is no “magic” temperature that we worry about more. Look at how your child is acting, not the thermometer, to determine if they are sick. Not every child with a fever needs to even be treated. There is benefit to letting the fever do its job!

Uncontrollable pain.

If you’ve used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.

Most rashes.

Though these don’t necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.

If your child is otherwise well appearing, treat the symptoms of the rash.

If he’s otherwise sick and you’re concerned, then he should be seen.

Chronic problems.

If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider. This is especially true if it relates to a chronic condition, such as asthma, constipation, or other issue.

Many parents deal with a problem for months (or years) but have NEVER been in to discuss it specifically. They might mention it at another visit as an aside, but we never really talk about it in depth and give it the attention it deserves.

Diagnosis vs information.

If you want a diagnosis, we need to see your child.  We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.

If you want advice of what to do with symptoms, we can generally give advice. Remember that the websites above can be helpful with this type of information too!

Behavior problems.

These are best discussed with your usual provider, not an on-call provider who doesn’t know your child. Most of these build up over time and are not emergent issues.

If it is an emergent issue, such as a child is in physical danger due to his actions or if a child is threatening another person, call 911.

If your child is suicidal, call the suicide hotline at 1-800-273-8255.

Injuries.

If your child has a significant injury, they often require prompt evaluation. Call 911 before calling your doctor’s office if your child is seriously injured.

Lacerations must be repaired as soon as possible, so don’t wait until office hours the next day if there’s a gaping wound!

Minor bumps and bruises can be handled at home, but if you’re not sure, give us a call to discuss what happened.

Help me help you!

Let me know what else you need to know to be an educated caller.

I’d be happy to answer questions about when to call, what to ask, and what to expect.

If I left any questions unanswered, please ask!

Share Quest for Health

Convenience Care

Healthcare is available at many locations, such as in the medical home (primary care office), at a specialty clinic, in a hospital or a surgery center, freestanding urgent cares, pharmacy based urgent cares, emergency rooms, telehealth companies, school health clinics and more. Convenience care is what I use to describe the care people desire here and now, when it’s convenient and where it’s convenient.

There are places that are best suited for one issue and others suited for other issues. Sometimes people choose a location based on what’s convenient at the moment, not necessarily when and where they will get the best care. This usually isn’t going to make much of a difference, but it can have implications of varying consequences. Convenience care is not equal to the best care, and sometimes not even equal to good care.

The one about the restaurant

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

source: https://commons.wikimedia.org/wiki/File:The_Simpsons_Ride_-_KwikEMart2.jpg

But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home.

Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well… convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent.

While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks.

The food wasn’t the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn’t of any use helping me decide if what we ate was good for us or not.

Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there.

Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it’s usual for Convenience Cooks to bill added fees. Again, they said they couldn’t do anything to help with the bill. For a Restaurant that is usually so helpful, I feel like they are dropping the ball because they won’t help with anything that was done at Convenience Cooks. It’s like they don’t have any responsibility for what I eat elsewhere.

The one about specialists

In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but they don’t offer slow-cooked BBQ, so they refer customers to BBQ-R-Us.

BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation.

When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask about how the ribs were prepared. You’re disappointed to hear that they can’t give details about the BBQ recipes and tell you to call BBQ-R-Us.

Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee. Again, Primary Restaurant isn’t very helpful in discussing the bill from BBQ-R-Us. They refer you back to BBQ-R-Us.

now change the names

Most people can see just how crazy it is for a restaurant to “fix” the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or regarding specialist referrals. The scenarios above are based on real phone calls about medical care. These phone calls are not only time-consuming and costly for medical offices, but they’re also frustrating for the people on both sides.

Convenience Cooks = Urgent Cares

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

It’s not that I’m holding a grudge or trying to be mean, but I really can’t help. If I didn’t see the patient or at least have access to the medical record of the visit and know the provider well enough to understand their practice style, I have no idea what was really seen and done.

If you call my office because your child is having a problem with a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that “they’re not open yet” or “they don’t do phone calls, they want us to come back.” Sorry. We will want to see your child before we treat him for this issue. You can bring him in or you can follow-up with the original prescriber.

On a similar note, if a patient sees someone else in my office, I can look at the medical record documentation. I know the people I work with well enough to know what they typically say and do, and along with their written plan I can usually offer assistance if they’re not available. Sometimes even then I will want to see a patient because symptoms change.

If someone outside my office sees a patient, I really don’t know what the level of exam was, the experience of the provider, or the specific details of the visit. Urgent cares are getting better at sending a summary of the visit to the primary care provider, but we still don’t receive any information a significant percentage of the time. Other than routine general advice, I can’t really say much about the issue. I cannot change or refill another provider’s order. I cannot order labs or x-rays based on another provider’s assessment. I believe that this is not good care and I would prefer to see the patient if they need advice or a change in the treatment plan from me. And I certainly can’t do anything about the bill from another provider.

Many problems seen at urgent cares can wait. I know it’s easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it’s strep throat and they start an antibiotic at 8pm, they can’t go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night.

The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)

There are now some urgent cares that are actually cheaper in dollars because of insurance contracts. I think this is a very short-sighted plan on the part of insurance companies and in the end will cost more in dollars and health complications. They are trying to save money by contracting with these urgent cares (or are merging with them). I worry that fragmented care will in the end increase costs because they won’t have access to a patient’s medical chart. Increased numbers of tests and prescriptions are often seen at ER/UCs compared to primary care offices because they don’t have a means to follow-up like the medical home does so they cover all the bases rather than take the watchful waiting approach that PCPs are able to take. At urgent cares patients will not have the benefit of seeing the same provider each time, so they will never develop the important doctor-patient relationship that can help if and when anything chronic develops.

BBQ-R-Us = Subspecialist Referrals

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

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

Expect higher fees any time you use a hospital based facility, whether it’s for an office visit, a lab, or a procedure. They not only have charges for the physician’s time, but they have facility fees to cover the costs of running the hospital.

The primary care physician cannot change the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do… I can’t even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that.

It’s hard to anticipate costs, and that’s a problem with our healthcare system. I know that, but it’s not in my control to fix that. Believe me, I understand as a consumer how frustrating and expensive healthcare can be.

We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn’t help plan before the visit. It only tells the maximum that will be charged, not the actual amount that will be the patient responsibility after insurance adjustment and payment. I understand how frustrating medical costs can be, but I can only help with what is in my control. Changing how our billing and insurance system works is not in my power. I can only play by the rules.

Evolution of Illness

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

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

sickness, cough, cold, getting worse

It’s been about 15 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn’t help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn’t make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments because my son had wheezing so we had everything we needed to give a treatment at home with a nebulizer. We did these treatments several times despite the fact that they didn’t seem to help her much. (Guidelines now say to not use bronchodilators for most infants with bronchiolitis but even then we knew it didn’t help much.) It was probably the humidified air from the nebulizer that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn’t helping, so I wanted to at least try the asthma medicine.

She kept wheezing.

We brought her in to the office three days in a row to have someone else check her. I can’t check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams.

She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times per minute for days. I still don’t know how. I remember wishing her oxygen level would drop enough that we could hospitalize her ~ not critically ~ just enough. Then she’d be on monitors and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick and eventually we were all sleeping again, but it took a long time for that.

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

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

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

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

When you hear that your child has a viral illness, do not take that to mean it’s “just a virus” and there’s nothing to be done. There are many supportive measures that can be done and things to monitor to be sure your child isn’t getting sicker. Dr. Jamie Friedman discusses the topic of Just a Virus and Dr. Chad Hayes also covers the difference between “just a virus” and the potential risks of a viral illness in “Just a Virus:” What Your Doctor Meant to Say.

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

  • Money is probably the biggest issue. It is not because we want your co pay. The “we” I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I’ve seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the copay because we did “something wrong” or “missed a diagnosis” the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate copay is charged. We must adhere to legal contracts or it would be considered insurance fraud.
  • Increasing our numbers for “production” is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don’t want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.
  • We want to see your child again because we need to see your child to know what to do. Maybe now the child’s symptoms have changed. Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever’s been going on long enough without any identifiable cause, which requires lab and/or x-ray evaluation.

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

Human bodies are not static.

Cold and Flu Season is Upon Us!

Every year at this time, I think about how our kids are managed when they become sick. Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care. During cold and flu season kids get sick. A lot.

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

Illness doesn’t work that way.

Most childhood illnesses are viruses and they take a few weeks to resolve. There’s no magic medicine that will make it better.

  • Please don’t ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.
  • Don’t ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.
  • Don’t ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.
  • Antibiotics simply don’t work for viruses. They also carry risks, which are not worth taking when the antibiotic isn’t needed in the first place.

Urgent cares are popular because they’re convenient.

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

Can it hurt?

Extra tests = Extra costs

Some kids will get unnecessary tests, x-rays, and treatments at urgent cares and emergency rooms that don’t have a reliable means of follow up. They attempt to decrease risk often by erring with over treating.

The primary care office does have the ability to follow up with you in the near future, so we don’t have to over treat.

No history

Urgent cares outside of your primary care office don’t have a child’s history available.

They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).

It’s easy to fail to recognize if your child doesn’t have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.

We know that parents can and should tell all providers these things, but the new patient information sheets in my office are often erroneous when compared to the transferred records from the previous physician. Parents don’t think about the wheezing history or the surgery 5 years ago every visit.

It’s so important to have old records!

Records in one place

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.

Is it time for further evaluation of immune issues?

When should you consider ear tubes or a tonsillectomy?

If we don’t have proper documentation, these issues might have a delay of recognition.

Not all locations are good with kids

Urgent cares and ERs are not always designed for kids.

I’m not talking about cute pictures or smaller exam tables.

I’m talking about the experience of the provider. If they are trained mostly to treat adults, they might be less comfortable with kids.

They might order extra labs or x-rays that a pediatric trained physician would not feel are necessary.

This increases cost as well as risk to your child.

Drug choice and dosing can be complicated for clinicians not familiar with pediatric care.

We have been fortunate in my area to have many urgent cares available after hours that are designed specifically for kids, which does help. But this is sometimes for convenience, not for the best medical care.

Cost

As previously mentioned, cost is a factor.

I hate to bring money into the equation when it comes to the health of your child, but it is important, especially with the increasing rates of high deductible health insurance – you will feel the burden of cost.

Healthcare spending is spiraling out of control.

Urgent cares and ERs usually charge more.

This cost is increasingly being passed on to consumers. Your copay is probably higher outside the medical home. The percentage of the visit you must pay is often higher. If you pay out of pocket until your deductible is met, this can be a substantial difference in cost. (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about the walk in clinic at your primary care office? 

Many pediatric offices offer walk in urgent care as a convenience for parents who are worried about their acutely ill child.

If your doctor offers this, the care given is within the medical home, which allows access to your child’s chart. All treatments are within your child’s medical record so it is complete.

Staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols the group has agreed upon. Essentially primary care pediatricians have a high standard of care and want your child to receive that great care in the medical home as often as possible.

Telehealth

There are more and more telehealth options offered by insurance companies and physicians. This is a new area that has exciting potentials, but I’m concerned about inappropriate treatments. It can be a great tool to follow up on ongoing issues, but is not appropriate for many routine earaches, sore throats, and other issues that require an exam and/or testing.

I know it’s tempting to call in to get a prescription for a presumed ear infection or Strep throat, but think about how those diagnoses are made and remember that overuse of antibiotics increases risks to your child.

So what kinds of issues are appropriate for various types of visits?

(Note: I can’t list every medical problem, parental decisions must be made for individual situations. For a great review of how to determine if it’s an emergency, see Reliable keys to identify a medical emergency from Dr. Oglesby at Watercress Words.)

After hours (urgent care or ER- preferably one for children):

  • Difficulty breathing (not just noisy congestion or cough but increased work of breathing)
  • Dehydration
  • Injury (including but not limited to bleeding that won’t stop, a wound that gapes open, obvious or suspected broken bone)
  • Pain that is not controlled with over the counter medicines
  • Severe abdominal pain
  • Fever >100.4 rectally if under 3 months of age or underimmunized. (There is no magic temperature we “worry more” if an older child is vaccinated.)

Walk in clinic (or appointment) at your primary care provider’s office:

Being sick isn’t fun, but sometimes it just takes time to get better while using at home treatments. Use the healthcare system wisely to get the best care.
  • Fever
  • Earache
  • Fussiness
  • Cough
  • Sore throat
  • Vomiting and/or diarrhea
  • Any new illness

Issues better addressed with an Appointment in the Medical Home:

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

telehealth

  • If your primary doctor (or specialist) uses telemedicine as part of follow up care this can be a great use of telehealth.
  • Be careful of “free” or inexpensive telehealth options from other groups, including those from your insurance company. A quick and easy fix isn’t necessarily a safe, effective, or needed treatment.
Getting appropriate health care is important. If you aren’t sure what the best plan of action is, call your doctor’s office.