Is There A Doctor In The House?

This week’s guest columnist is Dr. Meighan Anderson, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

She’s 10 years old.  She has asthma and eczema, but hasn’t seen her regular doctor in a year- her pediatrician retired and mom hasn’t found a new doctor yet- life’s so busy!  Yet the girl has had several asthma flares requiring Emergency Department visits. The itching from her eczema is also making life miserable, with sleepless nights and scaly skin.  Visits to walk-in clinics have yielded treatments that haven’t worked.

Many kids don’t visit their regular doctor enough.  When they get sick, Urgent Care clinics are so convenient.  Sometimes the family’s moved and not found a new doctor locally.  Sometimes their doctor has retired, or doesn’t take the family’s new insurance.  We also hear a lot of “he’s never sick, he hasn’t needed a doctor,” in the ER.

Having your own doctor is more important than many realize, especially for kids with chronic conditons like our 10 year-old asthmatic.  For kids with these issues, only their doctor has reliable records of what has already been tried, what worked and what hasn’t.  Office-based doctors are better trained and more experienced with these conditions too, rather than Urgent Care or ER providers, whose focus is acute illness.    Finally, office doctors are where to go for vaccinations, school physicals, and specialist referrals.

The first step to find a doctor is your insurance.  If your child has medicaid, only certain practices accept that, though most pediatricians take some medicaid patients.  If you have private insurance, that company will provide a list of accepting doctors.  Office location is important too- shorter trips from your home are helpful with busy lives.  Then you need to decide what kind of doctor to pick.  If your child is newborn through teenage years, a board-certified pediatrician is best.  If your kid is a late teen, soon to be 18 years-old, a Family Practice or Internal Medicine doctor is better, since they can take care of him into his adult years.  They take care of parents too!

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul.  Although the two cannot be separated.” -Plato

Though Plato wrote this over 2000 years ago, it’s still relevant.  Above we discussed finding your child a doctor- insurance accepted, location, and specialty (Pediatrics, Family Practice, Internal Medicine).  But is the physician right for your child’s body and soul?  And your soul too?

Cultivating the doctor-patient relationship is important to successful care.  One of the  determinants in this is a practice style called “shared decision making.”  This is where you and a doctor negotiate what is possible for care, rather than the doctor dictating what you should do, and you being expected to follow blindly.

What does shared decision making look like?  In some cases, there isn’t much sharing.  Technical issues are decided by the expert- the doctor.  For example, your child has a sore throat.  It could be a virus and resolve in a few days, or strep throat, requiring an antibiotic.  A strep test is done, it’s negative, and the doctor doesn’t prescribe an antibiotic, because it won’t help and may have side effects.

But what if your child always has a sore throat and it seems allergic?  With chronic illness like allergy, where lifestyle affects your kid’s illness, shared decision making is a must.  Should you go to an allergist, or would this be too much trouble, or does the thought of skin pin-prick allergy testing freak you both out?  Should you try some anti-allergy medication first?  Which one- inhaled, sprayed in the nose, or swallowed liquid, or a pill?  Which will your kid tolerate, and which is most effective?  Can you afford to tear up your carpet and put in hardwood floors for better dust control, and what about the smokers in the house?  Will they quit, can they quit?

All these questions should be explored with your doctor.  What is doable, what is best for your child, what can you and your kid tolerate, to optimize your child’s care?  Together you all decide on realistic goals and expectations.  In the old days, the doctor was always the boss.  These days, to deliver the most effective care, sometimes she’s boss, sometimes you are, often you’re co-captains of the team 

How Doctors, And Parents, Talk

Many doctors, including me, go “harumph” when parents bring their child to the Emergency Department with non-emergencies, like rashes or insect bites.  Non-emergencies are what doctors’ offices are for.  However, often when I talk to the parents, they relay a hidden fear that they feel couldn’t wait for their doctor.  ”My father-in-law had the flesh-eating bacteria and almost died!”, they’ll say.  ”Does my child have it too?”

This illustrates the importance of good communication between doctors and parents. When doctors go into exam rooms with bad attitudes, glance at the rash, grumble about parents wasting their time, and zip out, they don’t get a chance to hear why the family’s there and allay their fears.

Doctors make about 85% of diagnoses by the history of the patient’s illness alone. This is also why communication is important- doctors need to be good listeners to make accurate and helpful diagnoses. Taking histories is a special skill doctors learn in medical school, polish in residency, and hone throughout their careers. I’m sure I take better histories now than I did, say, 10 years ago.

However, doctors are often pressed for time, particularly in ERs, and feel they can’t take lots of time to listen.  Here’s the data- a patient or parent, given about 90-120 seconds, will tell the doctor most everything she needs to know to make the correct diagnosis. Not a real time sink!  However, data also shows that most doctors interrupt the patient’s story after about 15 seconds, start asking yes-or-no questions, and shut down the patient’s narrative.

Specialists are another group besides ER doctors, that may not listen to a patient’s whole story. Since they have patients referred to them from other doctors, some feel that the patient’s story has already been told, is in the record, and doesn’t need repeating.  However, the best specialists take their own histories from the beginning. Who knows what new clue the patient will reveal in the retelling, that may make the diagnosis the referring doctor missed?

Specialists often get patients with complex stories referred to them.  After all, if the diagnosis was easy, the generalist would have made it already, right?  But one complex issue generalists often see is abdominal pain.  The abdomen is full of different organs, hidden deep inside, and each organ has several ways to go wrong. Many times a certain organ’s symptoms mimic it’s neighbors.  The ovary on the right side hurts when it develops a cyst, but that hurts a lot like when the adjacent appendix gets infected, or nearby bowel gets full of gas.

As we mentioned above, specialists should often have patients repeat their complicated stories to reveal clues the referring doctor missed. But all doctors should take careful, thorough histories with belly pain. Sometimes after I’ve taken the history of a teenager’s abdominal pain, done the exam, and discussed it with her and her family, I’ll return later with new questions.  I’ll be writing in the chart and think- “did I ask about urinary symptoms?”  I’ll pop out of my chair and revisit that with the patient. After tests come back, they might suggest another possible diagnosis, and I’ll go ask about that. And every once in a while, say on my third or fourth trip into the patient’s room, they’ll give me the crucial clue, like “Well, she is seeing a GYN doctor for her ovarian cysts.” Why didn’t you tell me that two hours ago???

Effective communication is a two-way street.  Doctors need to listen to the patients’ stories, and parents and patients need to be prepared to tell the story too. If the doctor interrupts because he’s interested in some point that’s brought up, be sure to continue the story after briefly answering his question.  If the doctor seems not to be listening, call him on it.  It’s okay to say, “Are you listening?” if he seems distracted.  Also, its okay to tell the doctor if you think he’s missing something.  You can say something non-confrontational like, “I’m worried my baby might have diabetes.  What do you think?”

Finally, it’s best to choose a doctor who’s a listener, before your child gets sick and it’s crucial.  A doctor receptive to your story is important to figure things out.  As the father of modern medicine, William Osler, said over 100 years ago, “Listen to your patient.  He is telling you the diagnosis.”

Why Is Your Pediatrician So Grumpy?

I was worried I had a brain tumor.  That afternoon at work, I began having double vision. I could correct it by tilting my head, but as the day went on I was talking with parents with my head cocked over more and more.  My Fourth Cranial Nerve was malfunctioning, a nerve that controls eye movement, and it was weakening by the hour. I needed an MRI and couldn’t get one where I worked at the time.

The next morning I called my internist to get seen, but the receptionist said, “Go see an eye doctor.”  ”You don’t understand,” I explained, “It’s a cranial nerve, not my eye, and I need to get seen.” She still stalled me until I pulled the “doctor” card, insisting I speak to my colleague.  She put me on hold, then came back on: “He said ‘go see an eye doctor.’” I hung up, not believing my ears.

Coincidentally I had a check-up scheduled that day with Dr. David Fisher, my optometrist. Fortunately, David knew exactly what was wrong. My vision was already recovering, and he explained that that nerve goes funky occasionally, especially in plumbers who bang their heads on the underside of sinks.  No worries about brain tumors, whew!  Then I found a new internist.

Why do doctors, supposedly caring professionals, sometimes act insensitive or downright grumpy?  It starts when applying to medical school.  You need good grades in a tough science curriculum to get in, and nerds don’t always learn people skills, being too busy learning study skills.  Then in medical school you are surrounded by other “medical nerds,” and don’t learn how to relate to non-scientists.

Then comes residency.  My father was a seminary professor, and once gave a workshop for hospital chaplains.  He told me of a priest who had observed that the hours are so long and punishing, the apprentice doctors in residency get the humanity “ironed out of them.” After graduating, some regain their hearts, some don’t.

All doctors get grumpy.  For me one time, it was a mom who kept interrupting. Her child had a headache, and I was explaining that I didn’t think she had a brain tumor, but needed a CT scan to be sure. But every sentence I started, before I could get to the CT part, mom cut me off with “that’s all stupid, I want a CT.” I finally snapped and shouted, “Shut up, quit interrupting, and I’ll tell you what you want to hear!”

Everyone, especially doctors, gets grumpy in “people” professions.  While most patients are nice and polite, some aren’t.  And doctors don’t always start life warm and fuzzy. As we discussed above, medical schools select for academic performers rather than kindly grannies with a twinkle in their eyes.  Then comes the rigors of residency, where long hours and crushing responsibilities turn the nicest guys into ogres.

After residency, the hours and the responsibilities don’t quit.  Fatigue is an occupational hazard, and one continues to have to make potentially life-and-death decisions all day. Doctors dread the patient coming back to the hospital, maybe dying, after making a judgement call that turned out wrong.  Dr. Richard Selzer explained this internal struggle best:

“Yet he may continue to pretend, at least, that there is nothing to fear, that death will not come, so long as people depend on his authority.  Later, after his patients have left, he may closet himself in his darkened office, sweating and afraid.”

So doctors sometimes get snappish, and may seem uncaring about your child’s suffering. Yet worry for patients caused the stress in your doctor in the first place.  So if your kid’s doctor seems grumpy, give him or her a break, a second chance to recover. If he continues to seem uncaring, get a new one.      

Trust Your Doctor! Or not.

All doctors get dogged by patients and parents for missing diagnoses.  I see it when a parent brings their child into the Emergency Department.  The kid has had a cold and fever for a few days, and their regular doctor called it “just a cold.”  When I examine the child, I find an ear infection.  The parent then says something like “Thank God I brought the baby back!  That other So-and-so missed the ear infection!”

At this point many doctors, including me, are tempted to take credit for being smarter than their colleague, and let the parents leave with the notion that I am somehow superior. Taking credit for hindsight, however, is unfair to the first doctor.  Diseases progress.  What started as a cough and runny nose virus in the child above can later, after the first visit, develop complications like ear infections or pneumonia.  I too have been complained about when I have diagnosed a cold virus, and later when the child was taken to another doctor, she was then diagnosed with pneumonia.  The family then complains because I “missed the diagnosis,”  even though pneumonia naturally develops later in cold viruses and the child truly had no pneumonia at the time I saw her.

Why do some families easily distrust a doctor?  There are several reasons, some because of the family, some because of the doctor.  The first family factor is that families care.  They love their child and when things go wrong they get worried, they get scared, they get angry.  Another factor is that families often know about someone who got sick, the doctor said things will be fine, and the patient went on to have cancer or worse.  Those family stories color any future encounter with a doctor.  Finally, people have come to take their child’s good health for granted and now expect only good outcomes from illness. One hundred years ago, every family was expected to bury a child or two because there were more deadly diseases around, and few effective treatments.  Now when things go wrong in any way, people are shocked and surprised, and angry.

Often, doctors don’t help families trust them either.  Doctors often seem too rushed to listen and examine patients carefully, and thoughtfully consider the diagnosis.  Doctors in practice are busy trying to see so many patients in a day, when there are weeks-long waits for patients to get an appointment.  Emergency Department doctors are in a hurry to see patients to clear the way for the next surprise emergency to rush through the doors.

Also, a doctor doesn’t usually get into medical school because he is a warm and fuzzy “people person.”  The main criteria for medical school admission is academic ability- being great at science and math.  But school smarts don’t not always go with charm and empathy.  Sure, medical schools are trying to let in fewer Sheldon Cooper types like from the TV show The Big Bang Theory.  But medical schools don’t yet have a really good way to figure out who is going to be a smart and caring doctor, and who will just be a medical nerd.

Finally, doctoring is difficult because medicine is a hard discipline.  Disease diagnosis is sometimes complex, and medical science’s understanding of disease and its progression is imperfect.  There is a lot to know, and a lot more that is unknown.  The best doctors get surprised by their own ignorance.  And in a difficult, stressful, and tiring profession, doctors get stressed and tired.  Then your doctor is really not good company.

So what do we want in a doctor, so we can trust him or her?  We want a doctor who is really smart and experienced.  We also want that doctor to be caring, to take time to listen to our problem, to be friendly and to like us and to do their best to help us.  Fortunately most doctors are just like that most of the time.  Only seldom is a doctor not smart or not caring.  If your doctor seems ignorant or uncaring every visit, change doctors.  And sometimes you have to give your doctor a break in order to continue to trust him.

Or not.



Who Is Your Child’s Doctor?

Every day families bring their kids into the Emergency Department with non-emergencies- runny noses, fevers, rashes, diarrhea.  Many of those times mom is a little embarrassed, and says “I called my doctor and they were booked, and they told me to come here.”  Or worse, the mom might say “My child does not have a doctor.”

Having a good doctor for your kid is important.  Then you have a doctor who cares, and listens. That doctor knows your child, and has the child’s past history at her fingertips.  You have a place to go for check-ups,  school physicals, shots, and questions.  If you go to the Emergency Department or a quick care clinic, good luck.  Maybe the doctor there will care or listen, maybe not.  Maybe they know kids, maybe not.  They certainly won’t know your child as well.

What if you are a new parent, or new in town?  What if you want to change doctors?  Here is some help to find a good doctor for your kid:

1.  The doctor is “board-certified” in Pediatrics or Family Medicine.  The national boards only certify those who show by testing and credentials that they are keeping up-to-date.

2.  Full-time practice.  It is important that your doctor and his covering partners are available when you need.  The best practices have evening and weekend hours for working parents.  Such practices have doctors with around-the-clock phone availability in case of emergencies.

3.  Competent over-the-phone advice.  Medical advice should be handled by doctors and nurses.  The scheduling secretary should not be giving you advice on the phone.  She is not trained for that.

4.  Reputation: having people recommend a doctor is nice, but one bad comment doesn’t mean the doctor is bad.  Even the best doctor can’t please everyone all of the time.  However, see if you can get a doctor’s recommendation on where to go.  Doctors work with each other all of the time, and know who are the hot shots and who are the slackers.

5.  Fellow of the American Academy of Pediatrics (FAAP, as in Scott Hamilton, MD, FAAP) or American Academy of Family Physicians.  This means that the doctor is a member of the national professional organization that provides him the most up-to-date information.

Given the blitz of advertising of doctor, clinics, and hospitals, these are hints that can help you find a good medical home for your child.

When you settle on a doctor for your child, then you really learn if they seem good or not.  The first thing you should notice is that your doctor is a good listener.  Listening to a child’s medical history is important.  As the father of modern medicine, William Osler, said, “Listen to your patient, he is telling you the diagnosis.”  85% of diagnoses are made from the history alone.  The physical exam and labs and xrays usually only help to confirm the diagnosis.  

Listening is a kindness, and other kindnesses should be apparent.  Nice and helpful secretaries and nurses are important.  It makes your experience better, and having them care about you and your child is just plain good medicine too.  These are people who get back to you in a timely fashion with appointments and lab results. Many times I have heard parents say they are changing practices not because of the doctor, but because of the “people in front.”

A kind and listening doctor is good, but the doctor who is also a thinker is even better.  Consider this: you are paying your doctor to carefully consider your child’s case.  Your doctor is not just a vending machine for antibiotics and steroids.  You want your doctor to take the time to explore a problem, answer your questions and consider your opinions, and give comprehensive and thoughtful advice.  Now, these things are hard for a doctor to pull off, in this era of doctor shortages, shrinking payments, full practices, and thus reduced times allowed for each office visit.  Your doctor should at least seem to make the effort!

So who is your child’s doctor?  Someone board certified?  Has good phone access and good people in the office?  Has hours that fit your work schedule?  Good!  Then you shouldn’t have to come see me.  Unless it is an emergency!

Picking A Doctor For Your Child

Every day several families bring their kids in to the Emergency Department with non-emergencies- runny noses, rashes, diarrhea.  Then many times the mom, perhaps sensing our impatience with the inappropriateness of that visit, state “I called my doctor and they were too booked, and told me to come here.”  Or worse, they might say “I don’t have a doctor for my child.”

Having your own doctor for your child is important.  You know you have a doctor who cares, and listens.  That doctor knows your child too, and has all the child’s past history at their fingertips.  You have a place to go for check-ups, sports physicals, shots, and questions.  If you go to an Emergency Department or quick-care clinic, its pot luck.  Maybe the doctor will care and listen well, maybe not.  Maybe they know kids, maybe not.  They certainly won’t know your child well.

What if you are a new parent, or new in town?  Or what if you want to change doctors?  Here are the things that help you find a good doctor for your kid:

1.  The doctor is “Board-Certified” in Pediatrics or Family Medicine-  The national boards only certify doctors who have demonstrated through testing and credentials that they are keeping up-to-date in their field.

2.  Full-time Practice- It is important that your doctor, or covering partners, are available as much as possible.  The best practices have evening and weekend hours for working parents.  And of course, the practice should have doctors with around-the-clock phone availability in case of emergencies.

3.  Reputation- it is nice that people you know recommend a doctor, but a bad comment doesn’t necessarily mean the doctor is bad.  Even the best doctor can’t please everyone all of the time.   However, recommendations from other doctors carry a lot of weight.  Doctors work with each other all of the time and know who are the hot-shots and who are the slackers.

4.  Fellows of the American Academy of Pediatrics or American Academy of Family Physicians-  These doctors will have the initials after their name FAAP or FAAFP, as in Scott Hamilton, MD, FAAP.  This designation is icing on the cake of Board Certification.  This means that the doctor is a member of the national professional organization that provides the most up-to-date information in their field.  The AAP and AAFP work with the national boards to develop practice standards.  The AAP and AAFP also are active politically to help governments in the United States and abroad provide the best care for children.

5.  The doctor is a good listener- as I have stated elsewhere in this blog, most diagnoses are made from the patient’s story, so your doctor needs to be a good listener to be a good doctor.   There is an old adage that you would rather have a mean doctor that knows the latest cures than a nice, hand-holding doctor that will kill you through incompetence.  In truth, wouldn’t you rather have both?  Professionalism demands that doctors be both good and kind listeners, and up-to-date in their practice. 

These days, with blitzes of advertising of doctors, clinics, and hospitals, these are the hints that can help you find a good medical home for your child’s care.