Things Your Mother Told You That Were Wrong

by Herschel Lessin MD

My first appointment of the day is a visit I enjoy immensely: the first well baby visit for a new mother and her newborn infant. At this visit, new mothers and very often new fathers, will have their first interaction with the Pediatrician. They usually come loaded with questions. After all, babies don’t come with an instruction manual. Despite the many books on the market that try to serve as one, there is nothing like a dose of reality to make the entire process seem nothing short of overwhelming.

EVERYONE IS AN EXPERT

If you’ve ever been pregnant or had children, you’ve undoubtedly noticed an odd phenomenon. People who normally wouldn’t even consider giving unsolicited advice about your personal life seem suddenly unable to suppress their desire to tell you all the secrets of delivering and raising a healthy and happy child.

Most of the advice is very good and will work very, very well. A lot of it, however, falls into the category of “Old Wives’ Tales”.

TO WHOM DO YOU TURN?

One does not have to be an old wife to pass along an old wives’ tale. In fact, a lot of what people call “common sense” is not really very sensible. As a parent, you must make decisions that affect your children’s lives, and yours as well. It is one of your many jobs as a parent to filter through the enormous amount of well meaning advice you receive and decide which of it is useful and effective.

Your Pediatrician ought to be of some help here. A large part of pediatric practice is the giving of advice that helps parents cope with the thousands of small day to day challenges that this new young person in their lives will bring. Your doctor should be ready, willing and able not only to dispense such advice, but to comment on advice given by others and found in the media (including the Internet). My job as the Pediatrician is to give you a convincing reason why my advice might be better than your mother’s.

OLD WIVES TALES ABOUT FOOD

The care and feeding of children is a fertile area for unsolicited advice. Feeding a child has an emotional impact that is often way out of proportion to the problems involved. This is easily understood, since if we can’t even feed our children, what kind of parents are we? The wonderful truth is that our kids seem to survive and thrive no matter how we try to feed them. Now I am not talking about families in which poverty prevents children from getting enough to eat. I am talking about middle class families where this is not an issue. Here are a few pieces of advice you ought to ignore:

If you don’t force a child to eat, he’ll starve. NOT TRUE.

Young children generally eat when they are hungry, rarely overeat, and refuse food only when it they honestly don’t want it, or if it upsets their parents enough to be fun. Never fight with a child over food. You will lose.

Early introduction of solids will make a young infant sleep through the night. NOT TRUE

Infants generally do not want or need solids prior to around 4 months of age. They will sleep through the night when they are good and ready. Giving them a few spoons of cereal at bedtime which contains perhaps 20 calories will not put them out for the night.

You shouldn’t give a child with a cold, milk because it causes phlegm.

Unless your child is one of the few that are actually allergic to milk, there is no truth to this one. If your child with a cold wants milk, give it to him. No harm done.

OLD WIVES TALES ABOUT FEVER

Fever and illness is another fertile area for bad advice.

“Feed a cold, starve a fever…” or is it “Starve a cold and feed a fever?” It really doesn’t matter, since both are wrong. Good nutrition is important to all children, especially sick ones. One should maintain the best nutrition possible, regardless of colds or fever. If a child has a stomach bug, some degree of dietary restriction is often suggested, but a quick return to good nutrition is always the goal.

A high fever is dangerous.

While the disease that causes the fever may indeed be dangerous, the fever itself is not. A fever in a child that is acting well is rarely a cause for alarm. The only exception to this is in the case of heat stroke, where the body’s sweating mechanism is not working. Then body temperature can rise to 107 or higher which is a danger all by itself. In the absence of heat stroke, the temperature will not rise more than 106, which while very scary, will not, in itself cause harm. A high fever can be an indication of a serious underlying illness, so high fevers should always be discussed with your Pediatrician.

Parents are constantly asking me if it is OK to give their feverish child a bath. It is OK. A lukewarm bath may help lower the temperature and may make the child look and feel better. So bathe away — it’s not a problem. Just don’t let the child get so cold as to shiver. That will raise his internal temperature and make him feel worse.

You must keep a head injured child awake. Not Always

If your child has a head injury that is severe enough to cause loss of consciousness, it is severe enough to seek immediate medical attention. If your child has a minor head injury, it is often normal to be sleepy, but not unconscious. Trying to keep such a sleepy child awake will only make him feel worse. One should check such a child frequently to make sure he is arousable, and always call your doctor for further instructions after any significant head injury.

OLD WIVES TALES THAN CAN CAUSE HARM

While most old wives tales cause only anxiety, a few can cause harm. The most common one is the advice to put something greasy like butter on a burn. This is dangerous. Grease will hold the heat inside the skin, deepening the burn and making it more severe. If your child is burned, the first thing to do is to get something cool, but not freezing, on it. This will reduce the heat and minimize the damage.

Poison ivy is dangerous if it involves the eyes.

Old wives’ tales also wrongly tell us that some very mild things are dangerous. Poison ivy on the face may cause swelling of the eyelids, but while this is very uncomfortable, it will cause no lasting harm. Oh, and by the way, poison ivy is caused by oil found on the plant. Once it is washed off, you cannot spread poison ivy by touching the affected areas.

Another worry is that one should not let a child cry because that will cause him harm or he’ll choke. This is not true. The only one harmed by prolonged crying is the parent listening to it.

COLICS

There are few things in life as miserable to live through as the first 3 months of life with an infant who has colic. The old wives will tell you that there is something that you are doing to cause the colic or that there is a real medical problem. Once a good physical examination has ruled out organic illness, you should realize that not only is it NOT your fault, no one has any idea what causes colic. It is extremely common, and that there is very little anyone can do to make it better. It will, however, magically go away after the baby is 3 months old, if you live that long.

A FEW MORE PIECES OF QUESTIONABLE ADVICE

Over the years, I have heard of more complaints and illnesses attributed to teething than almost any other cause. Some facts about teething. First of all, it rarely is severe enough to wake a child up at night out of a sound sleep. If your child is up at night and has a cold, think ear infection, not teeth. Teething does NOT cause fever. It does not cause congestion or mucus and it does not cause diarrhea. It can make an awake child irritable and is best dealt with by either occasional use of rub on anesthetics or by giving a dose of acetaminophen by mouth.

Another thing new parents are often told is: “Don’t pick the baby up all the time, you’ll spoil him!” This is absolutely wrong. Young infants need to be picked up a lot in order to have normal psychological development. As they get older, they can be spoiled, but rarely by paying attention to their legitimate needs.

I am also amazed at how important it is for people to have their children be “regular.” Perhaps it’s the influence of all those laxative commercials. Being regular is of no importance to young children. Most children will find their own pattern and timing of bowel movements, from once a day to once a week for some infants. Going once a day is not special.

I’ll finish up with feet. I’ve never understood why so many grandparents feel that if you let a young infant stand up, he’ll get bow legs. He won’t. And believe it or not, buying an infant an expensive pair of shoes will not prevent flat feet. Aside from the fact that all infants have flat feet, this is rarely, if ever, a problem at any age as long as the foot is flexible. In any case, shoes make absolutely no difference.

CONCLUSION

Bringing a new baby into your lives is an exhilarating and exhausting experience. It can provoke a great deal of anxiety. I encourage new parents to seek out advice from any source of support that you can find. Just be sure that the advice is good advice, so you don’t fall victim to old wives’ tales.

Dr. Lessin has been practicing Pediatrician in the Hudson Valley since 1982. He is a founding partner and serves as both Medical Director and Director of Clinical Research at the Children’s Medical Group

Is Bigger Better? Considering A Hybrid-Concierge Model

Written by: Jennifer Gruen MD

In today’s medical practice environment, many will argue that the bigger the practice the better.  Better to pool resources, share call responsibilities, disperse the ever-increasing costs of technology and office staffing.

But what if you like small?  What if you went into medicine dreaming of knowing all your patients by name, being a part of their lives beyond the few minutes of their yearly physical, having time to chat about those Yankees instead of rushing off to the next, and the next, room…

My business partner and I were those dreamers.  We had each spent years at large pediatric practices- well run for sure, but not professionally satisfying for our personal needs.  We met working as associates for a small “country doc”, who operated a low volume pediatric practice in the suburbs of Connecticut, making ends meet by working out of a home office, and pretty much operating in the red until the day he retired.  Clearly not a business model we wanted to adopt.

Add the fact that we both wanted to work “part-time” (we each put in 3 office days a week- many more hours at night on the business, but at least we have daytime hours to spend on household needs and kids.)

We spent a long time debating how to set up our own practice, reading SOAPM posts religiously for any helpful hints.  We debated becoming a concierge practice, fee-for-service/no-insurance or hybrid concierge model.  What we settled on was a pleasing mix that has sustained a growing practice in the 2 ½ years we have been open.

We settled on a few basic ideas- first, we would limit insurance to a few select plans that paid appropriately for our services.  Given our history with a variety of insurance companies, Oxford/United was never considered.  We would rather see one better paying plan X patient for a relaxed visit, than jam in two patients with plans that paid half of X’s rate.  Many of our patients on Oxford/United still elect to see us out of network for our service.  Second, we agreed that we would accept a small number of managed medicaid patients- we had a dedicated group of wonderful patients with this plan, and we were willing to sacrifice some income to continue serving these families.

We started out as a 2 person partnership, with a goal of adding a third, but no more than that.  This rubbed my business minded husband the wrong way- why not expand if you are growing and successful?  For a few simple reasons- we never wanted to be so large that we couldn’t each know the majority of our families by name.  We had also agreed not to use an after-hours telephone triage service, and that meant limiting patient number to limit phone calls to a reasonable amount.  Three docs meant every third weekend on call- not so onerous if our small practice generated only a few weekend visits sandwiched between our kids’ soccer games and birthday parties.  The stress of seeing 40-60 patients on a Saturday in my previous practice would ruin those weekends for me, even if I was on-call fewer weekends out of the year.

Most importantly, we decided early on to charge a mandatory “added benefits” fee- a modest per child charge to cover the many and varied uncovered costs of practicing medicine.  This was a lesser voluntary fee initially- promoted to the patients as a way of prepaying for multiple school and camp forms, and helping subsidize our somewhat unique (for the area) practice of not using after-hours nurse triage.  After a year, it became clear that we were providing these services for all patients though only a minority opted to prepay.  Also, by now these patients were well-acqainted with our quality of service, and word was beginning to spread.  We decided to limit our practice numbers, typically seeing 20-25 patients at most during an average day.  To make this financially feasible, we instituted our mandatory benefits fee, careful to be clear that it was for “uncovered fees” such as ACCESS to the physicians after hours (not the phone calls themselves, which we could rarely charge for anyway as those were usually related to a past visit, or resulted in a visit the next day.)  Also included are unlimited camp/school forms.

But underlying this charge was the emphasis on it allowing patients to experience convenient, personalized and unhurried medicine- something commercial insurance plans would never be able to cover.  Note that we live in an upscale area of Connecticut, making this fee affordable to most.  Our patients, in fact, draw from across the economic spectrum.  Very few objected to the fee, even fewer left the practice because of it.  Several have returned. Patients new to the practice accept the fee generally without question, often knowing what they will receive is priceless- that extra few minutes in the room with a physician, and many fewer minutes out in the waiting room with a sick child.  Time is money to many.

We waive the fee for parents with significant financial difficulties.  Because we tend to know our families well, we know when a parent has lost a job or is ill, placing financial strain on the family.

So is smaller better?  No, just different.  And better for me and my preferences.  Better seeing those 60 weekend patients spread out over 10 weekends instead of just one, making weekend call a quick trip to the office between gymnastics drop off and grocery shopping, an evening on call a message or two between dinner and homework help instead of in my office on the phone continuously between 6 and 12 pm while my husband handles the kids on his own.  And by charging the added benefits fee, I feel better knowing I am in some way compensated more appropriately for all the little extras I do for my patients day in and day out (and nights too….)

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.

An Ounce of Prevention. Supporting Breastfeeding Saves Money

Written by Jennifer Shaer MD., FAAP., IBCLC

Why don’t insurance companies cover breastfeeding services? As a pediatrician and breastfeeding medicine specialist, I’d like to add my perspective to the discussion. I do not want to detail the health benefits of breastfeeding. The benefits are numerous and deserve a separate story. My goal here is to point out that supporting breastfeeding saves the country money.

I would like to bring attention to a couple of publications. The Department of Health and Human Services has a publication called “The Business Case for Breastfeeding”. This publication highlights the financial benefits to breastfeeding. It shows how breastfeeding working mothers have lower absentee rates and lower turnover rates. Breastfed babies utilize fewer healthcare dollars. The publication features a number of companies that have saved hundreds of thousands of dollars annually simply by implementing lactation support programs in the worksite. You can view this publication here .

Just last year there was a study titled “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis”(PEDIATRICS (doi:10.1542/peds.2009-1616)) reported that if 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion dollars per year.

The evidence is clear. Breastfeeding improves health, saves money for insurance companies, for corporations, for parents and for WIC programs. Investing a small amount of money to support breastfeeding will bring huge financial savings to us as a nation. Why are the insurance companies too short -sighted to see the benefits of supporting breastfeeding?

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York. Dr. Shaer is dedicated to helping nursing mothers achieve their breastfeeding goals.

Vaccine Refusal Endangers Everyone. Why your pediatrician may refuse to treat your child if you refuse vaccines.

There is a lot of debate in the pediatric community whether it is appropriate for pediatricians to stop treating children if their parents refuse vaccinations. I caught up with Dr. Herschel Lessin, founding partner at the Children’s Medical Group to ask him what he thought of this debate.

Dr. Lessin, do you think pediatricians should stop treating parents that refuse to give their children immunizations?

Prevention of childhood illness is the heart of a pediatrician’s mission. Immunization refusal violates that mission, putting everyone at risk. If we allow families to remain in our practices unvaccinated, we are giving tacit approval to parents that refusing vaccines is just fine. It is anything but fine.

You said it puts everyone… how so?

First and foremost, the unvaccinated child is at risk to acquire deadly diseases with which few pediatricians have any familiarity (due to the success of our immunization programs). Second, other infants, children and parents present at pediatricians’ offices are at risk. If an unvaccinated child contracts vaccine-preventable disease and comes to one’s office for care, every patient one sees that day is potentially exposed. Sadly, this is not a hypothetical situation for my practice and for many others around the country.

Pediatricians are put at risk as well. In the above situation, I must call every patient exposed, upset them, and provide services to their kids that would never have been needed had the parents of the index case been responsible. Furthermore, if I allow unvaccinated patients in my practice, I must remember to ask every ill child whose parents call me whether they have been vaccinated. I must consider invasive for infections (including spinal taps) that I have not done in decades for simple febrile illness, and would have no need to do, had this child been effectively immunized.

Last, vaccine refusal is a danger to society and a public health hazard. When a large enough population is unvaccinated, herd immunity is lost. One only has to witness the many infants who died in the recent pertussis outbreak in California – a hotbed of anti-immunization fervor – to realize the impact. The current measles outbreak in the Somali community in Minnesota is another most unfortunate reminded when enough members of a community refuse to allow their kids to be immunized by fear conjured up by a single fraudulent and now repudiated study.

In addition to putting everyone at risk, it seems there is a non-compliance issue as well.

Yes, refusal to vaccinate is a marker for noncompliance with medical advice. If the parents don’t believe me when I tell them vaccinations are safe and important, are they any more likely to accept my advice about diet, illness, or medications? What if the unvaccinated child contracts a preventable disease? The parents might file suit, claiming that they were inadequately informed about the benefits of the vaccine or the risk of refusing it.

What is the American Academy of Pediatrics take on this issue?

The American Academy of Pediatrics has a somewhat different outlook on this issue. They discourage discharging patients solely because of vaccine refusal. However, they do acknowledge that the relationship might not be able to continue if there is a high level of distrust or major differences in the philosophy of care.

As a pediatrician, what does it come down to then?

For me, it comes down to whether you can have a relationship with a family when their choice not to vaccinate goes against pediatric core values and puts so many innocents at risk. I don’t believe that I can have a functioning doctor-patient relationship with parents who aren’t willing to accept my advice about such a critical issue as keeping their children safe from potentially deadly diseases. I have practiced in an era when these diseases were common. I do not wish to return. Being codependent with the baseless and disproven anti-vaccine movement is not a choice we should be willing to make.

The Nurse Will See You Now

Written by David Sprayberry M.D.

Something has got to change.

In recent years, the practice of medicine has been under attack from a variety of sources. Insurance companies continue to squeeze both physicians and patients in order to increase their already enormous profits. Our federal and state governments have decided to target physicians when an error is made in the exceedingly complex billing process in order to levy fines and recoup some of what they spend on Medicare and Medicaid.

Our federal government purposes to replace physicians with cheaper, lesser trained individuals who have not received nearly the level of education that physicians have. Even other healthcare professionals who have traditionally been a part of the physician’s team are seeking to take on the role of a physician and become your “provider.”

I fear that the best and brightest students will increasingly choose careers other than medicine if we as a nation continue to demean the work that physicians do and continue to attack the physicians who entered the field with altruistic intentions. It is also quite possible that the U.S. will lose practicing physicians to other nations that value their services more highly or at least do not make it as painful to do their jobs.

The American public needs to spend some time thinking about what they want from our medical system. Do they want their primary physician to be merely a coordinator of care or do they want him or her to be the provider of care? Do they want nearly all their office visits to be performed by a nurse who only calls in the physician if something is complicated or do they want a physician who is capable of detecting serious problems based on subtle findings or symptoms? Do they want to see a nurse when they go to a specialist? Do they want the person who is deciding whether they may have cancer to be someone who has never spent sleepless hours at the bedside of someone dying of cancer? Do they want the person who is deciding whether their child should be admitted to the hospital to be someone who has never seen a patient progress from simple wheezing to respiratory failure and death in a matter of hours? Do they want the person counseling them on whether to get that new vaccine to be someone who has never taken care of a child who died from a vaccine-preventable disease?

Our current system continues to march toward having nurses provide medical care and physicians only supervising and taking care of “complicated things”. Is this really what we want?

Dr. Sprayberry is a practicing pediatrician in Watkinsville, GA and blogs at Pediatrics Gone to the Dawgs

Why Do We Need A Doctor’s Note to Apply Sunscreen?

Written by: Kerry Frommer Fierstein, MD, FAAP

Parents make decisions for their children all the time. It is part of the job. Breast or bottle? Cloth or plastic? And that is just the beginning. By the time a child enters school the decisions a parent has made number well into the thousands.

Medical decisions are just part of the job description as well. Is my child sick? Does she need to go to the doctor? Should I put ointment on his cut?

Yet as soon as that child walks into a New York school, that same parent can’t approve the use of sunscreen on a school trip unless a physician signs off on it.

This upsets me on so many levels.

As a parent, I don’t understand why I can’t ask the school nurse to give my child a simple over-the-counter medication – the same medication I bought without a prescription and gave my daughter before she got on the school bus.

As a pediatrician, I can’t imagine a circumstance where sunscreen or bacitracin would be bad for a child, unless there is an allergy, which I depend on the parent to give me this kind of history anyway.

In my busy home life, I don’t need the unnecessary procedures involved with getting the doctor to sign off on over-the-counter medications.

In my busy practice life, I don’t need yet one more unnecessary piece of paper demanding my attention.

As a parent and a physician, I would like the schools and the government to remember that parents make health decisions every day, decisions much more important than sunscreen, bug spray and Tylenol.

Dr. Fierstein is a practicing pediatrician. Born in the Bronx and raised in Queens, Dr. Kerry Frommer Fierstein is a New Yorker all the way. She works at Pediatric Health Associates, PC, a division of Allied Pediatrics of New York.

Why Can’t Pediatricians Prescribe Medicine Over the Phone?

By Suzanne Berman, MD

“I’m sure it’s just an ear infection,” his mother said, pleadingly. “I don’t want to drag him in to the office in this weather. Why won’t you please phone in a prescription for an antibiotic?”

“But I need to be sure,” I said into the phone, trying to explain. “Can you bring him in? What if it’s something worse than an ear infection?”

“I’m telling you,” replied his mother, “it’s an ear infection. Just like before. All he needs is the prescription. I don’t see why you just can’t do this over the phone. It’s so simple!”

If you’ve ever been frustrated by a conversation like this with your pediatrician, I sympathize with you. These calls are frustrating for us pediatricians too – we want to keep our patients happy by minimizing expense, lost time, and anger. A lot of the time we can help you out over the telephone without making you come in to the office. In fact, studies have shown that pediatricians perform up to 20-30% of all care over the telephone, more than any other medical specialty. So in that regard, pediatricians are really the experts at maximizing telephone care for efficiency and safety. So when your pediatrician seems hesitant to issue a prescription over the phone without first seeing your child in the office, here are some things to consider.

The pediatrician can trust you 100% as a parent while still doubting your diagnostic powers.

“But you don’t TRUST me,” moms will say. That’s not quite true; I trust that your child really does have ear pain, and I trust that you think your child has a simple ear infection. Most of all, I trust that you’re doing the right thing by calling me for help. But you’re correct, I don’t 100% trust your diagnosis. Pediatricians are continually evaluating a child’s signs and symptoms in terms of a “differential diagnosis.” That is to say: the most likely cause of this child’s belly pain is a stomach bug. But other things it could be might include food poisoning, constipation, or appendicitis. We don’t want to get so locked down in one diagnosis so that we ignore all the other possibilities. So not trusting your diagnosis isn’t a slight on you; it’s how I was trained to think. Come to think of it, I often don’t 100% trust the diagnosis of the ER, the prompt care clinic, or the school nurse – and they all probably have a lot more medical training than you do. I often want to say, “But I’m telling you, I need to take a look in that ear. Why won’t you trust ME?”

It may not be as simple as you think.

Over the years, I’ve seen hundreds, if not thousands, of kids whose parents were convinced their child had an ear infection because of his ear pain. Much of the time, they’re absolutely right: that kid had an ear infection, and he needed antibiotics, just like Mom and Dad thought. But much of the time, Mom and Dad were wrong: the ear drum was normal, or the child had a swimmer’s ear infection (needing ear drops rather than antibiotics by mouth), or it was a gigantic plug of ear wax. Parents might not be too concerned if their child gets unnecessary antibiotics in these circumstances. But I’ve also seen children whose parents swore up and down their child had a simple ear infection, when the child did not have an ear infection, but rather had:

• A small toy wedged up against the ear drum
• A completely ruptured ear drum
• A tumor on the ear drum (cholesteatoma)
• An ear tube eroding into the tissue around the ear drum
• An insect crawling around in the ear
• Mastoiditis (a life-threatening infection of the bones around the ear)
• An abscess of the tonsils
• An abscess in their neck
• A dental abscess
• Leukemia
• Meningitis

The devastation of not picking up these conditions quickly vastly outweighs whatever convenience exists in phoning in antibiotics for your child. How could you continue to trust me after I failed to identify these serious but treatable illnesses in your precious son or daughter?

There’s power in a visual.

Let’s say you’re rear-ended at a stop light. You escape injury, but your rear fender has some dents and dings. Trying to get some estimates, you call a body shop and say, “Hey, I was in a minor fender bender. How much will you charge to fix it?” The auto shop says, “Hmm, well, there’s fender benders and then there’s fender benders. You should probably bring it in so we can see what the extent of damage is.” Then you say, “But I’m telling you, nothing’s affected but the rear fender. There’s a small dent. My car is a 2005 Accord. Just give me the estimate over the phone, please.” The auto guy says, “That’s really hard to say. I can’t make a proper estimate without eyeballing it.” Then you say, “But I’m trying to get three estimates by the end of the day. No way can I take my car to all 3 body shops. Just give me an estimate!” At this point, the auto guy might politely decline to do business with you. While the damage may be obvious to you, it’s not to him, and you may not be giving the kind of details or definition that allows him to make a good determination over the phone. Also, you’ve seen it: If your spouse calls and says, “Honey, I dinged the car…” you still want to see for yourself what the damage looks like. Does that mean you don’t trust your spouse?

Please don’t ask your pediatrician to violate her conscience.

I might drag you in unnecessarily for a simple ear infection that you had all figured out. You have the right to be disappointed, change doctors and move on, if you want; your child, your choice. But if I miss something that threatens your child’s hearing or life, I’ll know how I failed for the rest of my life. Since I have to live with my conscience, let me drag you in, even if you’re sure it’s unnecessary. If it’s really that you can’t afford another copay or missing more time from work, I totally get that. But you have to be honest; if that’s so, tell me. I could make a house call; I could stay late or come early before you have to be at work; I could write off the cost of your office visit. Those things are negotiable. But asking me to violate my conscience isn’t.

Respect the face-to-face medium.

Michael Foster posted a fascinating essay about the power of the face-to-face message:

A face to face breakup requires a degree of bravery. He has to say those words to wet eyes and quivering lips. He has to be aware of his tone and non-verbal communication (e.g. body language). A text message breakup is cowardly and insensitive. It communicates detachment, coldness, and disregard. The words are almost pointless. The medium overpowers them…. Everyone should know that a message is deeply tied to its medium. If you change the medium, you change the message.

In the same way, electronic or telephonic pediatric healthcare sometimes leaves out important elements. If you call me for advice about your colicky baby, I can tell you five things that will help soothe and settle her. But I can’t see your eyes – to see how upset you are at the constant crying. I can’t see your partner’s eyes, to see how worried he looks when he sees how exhausted you are. I can’t see your hands tremble, as you describe how you rock her hour after hour without improvement. I can’t see your eyes tear up as you think about another sleepless night. And you can’t see the concern in my eyes, or the inclination of my posture, or the tilt of my head to know: Yes, I am really listening to you. Yes, I am truly concerned for your baby. Yes, this is a fixable problem. While you may not need this certainty and comfort with your child’s earache right now, there may come a time when you might benefit from it. So if I suggest an office visit, it might be that I want to see your eyes.

Suzanne Berman is a practicing general pediatrician in rural Tennessee. She admits to, uh, being experienced in getting estimates for dinged fenders.

Why Your Doctor Chose to Be Your Doctor

Written by David Sprayberry MD

Probably the most common answer in medical school interviews to why someone is interested in entering medicine is “to help people”. The reason it is such a common answer is not that it is the “right” answer. In fact, most interviewers would probably rather hear something different than “to help people”, just to relieve the monotony of the interviews.

The reason it is a common answer, though, is that you have, at a minimum, seven years of physically and intellectually demanding education and training above and beyond your undergraduate education before you begin to practice independently. By the time the training process is completed, you will have devoted 24-28 years obtaining the education necessary to enter your career.

While you are devoting upwards of 100 hours per week for at least seven years to your courses, study, and training, your friends are enjoying their twenties. They are earning a living, going out, attending sporting events, traveling, dating, marrying and starting families. They are no longer accumulating educational debt. They are beginning to pay off the debt they do have. They are advancing in their careers.

You are struggling to get enough sleep to stay awake in class the next day, or during the seemingly interminable internal medicine rounds (which involves a short time seeing patients at the bedside and a great deal of time sitting in dimly fluorescent-lit conference rooms discussing those patients and their extensive lists of problems and medicines).

You are spending your nights and weekends trying desperately to prepare for the next anxiety-producing board exam, the next presentation before your attending physicians who are ready to pick apart whatever you present, or trying to unravel the mystery of the dying patient that just doesn’t seem to respond to anything you do.

The reason “to help people” is the most common reason for wanting to pursue medicine as a career is that you must make tremendous personal sacrifices just to begin your career. Friendships must be discarded or neglected. Entertainment and other enjoyable activities must be greatly reduced for quite a long time. Marriages are strained and often fail during this period. Indeed, certain residency programs have a greater than 100% divorce rate.

You must truly believe that what you are pursuing is a worthwhile endeavor in order to make such great personal sacrifices.

Dr. Sprayberry is a practicing general pediatrician who believes there is more to medicine than shuffling patients in and out the door. Dr. Sprayberry blogs at Pediatrics Gone to the Dawgs

In the hospital with Julia

By Suzanne Berman, MD

Edwin Leap, MD, an emergency room physician, makes a touching plea to those of us in rural medicine: don’t abandon your inpatient practice and night call responsibilities.

He articulately describes white coat flight – the trend away from inpatient and ER call as many primary care physicians, and even some specialists, drop their hospital privileges in search of fewer hours, better patients, and better pay.   But he doesn’t address my major ongoing apprehension about inpatient care: frustration with the hospital milieu.

I like working at my office.  I can always park where I want to.  It’s laid out how I like, with all my stuff clean, functional, and close at hand.  And if something breaks, or someone builds a better ZXK Analyzer 2000, I can buy another one if I want.  But the main reason I like working at my office is: I have a great staff team.  Our nurses are cheerful, helpful, compassionate, and solid.  I know this, because I’ve worked with some of them for nearly ten years.   They know how I communicate, what worries me, what I do well, and what I need help with and when.   Similarly, they’re great at serving our patients without constant micromanaging, because they ask for help when it’s not clear what to do.  We’ve worked together so long, day in and day out, in sickness and in health, that we truly work well as a team.

Let’s contrast this empowered team with the inpatient experience of, oh, say, the same pediatrician at a smallish community hospital.   Because we’re physically removed from what’s happening with our patient 23 hours of the day, we have a lot of catching up to do in the remaining hour at the hospital.   And rather than an “hour of power,” it’s often marked with frustration:

Me: “Wow, this output log said Johnny hasn’t peed since yesterday afternoon.  Has he really not urinated in over 16 hours?”

Nurse: “Ummm… hmm, I don’t know.  Night shift didn’t tell me anything about his urine.”

Me: “That may be, but if he hasn’t peed in 12 hours, we might have a problem.”

Nurse: “Well, maybe he’s peed.  His mom has been changing his diapers.”

Me: “Well, if she’s changing diapers, then he’s peed.  So why didn’t night shift record his urine output like we asked?”

Nurse: “I don’t know.  You’d have to ask night shift.”

Me: “Well, night shift isn’t here.”

Nurse: “I’ll ask if mom can at least remember how many diapers she’s changed.” [leaves, comes back] “Oops, mom went home to get a shower.  Dad is here now.  He doesn’t know anything about diapers.  He hasn’t changed any in the past 5 minutes.”

Me:  “OK, well, please page the nurse supervisor to get a hold of night shift.  Because I’m really worried about this baby’s kidneys now.”

[ten minutes pass]

Nurse Supervisor arrives.

Nurse Supervisor: [after the above is relayed]  “Oh, OK, I’ll find out.”

[twenty minutes pass. My hour is up.  I need to be back at my office.]

Nurse Supervisor: “OK.  I got a hold of night shift.   She knows the baby peed but doesn’t remember how much.”

Me: “But why didn’t she write it down in the log?”

Nurse Supervisor: [shrugs] “Maybe it just didn’t seem that important.  But we can discuss it next month at our inservice.”

Nurse:  “How can you measure how much a baby pees, anyway?  It’s not like the baby can pee in a urinal.”

Nurse Supervisor: “I hope you don’t expect us to straight cath babies!”

Me: [surprised] “You do diaper weights.  Weigh the diaper dry, then put it on the baby.  When it’s wet, weigh it again.  The difference is pee.”

Nurse Supervisor: [frowning, peering at chart] “Doctor, you actually didn’t write an order for diaper weights.  Just urine output.”

Nurse: [thinking through the previous instruction]  “….But that would give you a weight in grams.  Do you want us to record urine in grams?”

Me: “No!  One gram is one milliliter of urine.”

Nurse Supervisor: “Also, the computer system doesn’t allow us to put in diaper weights.”

Nurse: “Oh, our scale is broken. We’d have to get a new one.”

Nurse Supervisor: [making note] “I can put in a Capital Expense Request Form.  However, I heard they’re not approving new expenses until the 3rd quarter.”

Me: “I. Just. Need. To. Know.  How. Much. This. Baby. Has. Peed.”

Nurse #2: [walking by] “Oh, I bet I know why that baby hasn’t peed.  Night shift told me they turned the IV fluids down because the rate seemed like too much for the baby, who was peeing too much.”

All: [????]

The hospital setting lacks the efficiency, communication, chain of command, and ready materials that I’ve come to expect in my office.

Julia Child could prepare a souffle anywhere, certainly, but she might find it difficult in my kitchen, which contains only one old wire whisk, spotty lighting, and an oven with an irregular temperature control.   If compelled to do so, she’d no doubt be asked by foodies why this souffle wasn’t up to her usual standards.  “Oh, you see,” she’d say cheerfully in her New England warble, “we’ve been camping in the country!”

But unlike Julia, I’m held to a high standard of care whether I’m at my office or some other place.  It’s fundamentally easier to deliver good care when I’m in a familiar environment, surrounded by people and equipment I trust, than when my critical information is delivered (or not) by people unfamiliar to me (who was the mysterious nurse called “Night Shift,” anyway?). White coat flight isn’t an isolated phenomenon.  Many hospitals struggle with “pink scrub flight,” or the mass exodus of well-trained nurses from front-line care to higher-paying administrative jobs with better hours and less stress.   The crusty nursery nurse who’s been there since I was a nursery patient, whom I know and trust to spot a sick baby at 100 paces, has been replaced by a rotation of a half-dozen part-time nurses whose training and experience are primarily in adult medicine, and whose names I’m still struggling to remember.  If I feel a nurse made an inappropriate or unsafe call, I can report it, but I’m not part of her training or mentoring process; that’s “an internal hospital matter.”

If Julia knows she’s going to be working in a less-than-well-equipped kitchen, she’ll be sure to bring her own $59 zester.  But hospital work requires, with few exceptions, use of hospital staff and hospital equipment, for legal reasons.  And on a witness stand, when asked to explain a child’s bad outcome,  I can’t wittily demur about the less-than-optimal hospital setting; I’ll have to say that I did my best given the shortcomings of our local community hospital, a damning statement in the eyes of trial lawyers.

Dr. Leap is an experienced emergency room physician.  I would imagine that his hospital emergency departments are well-managed such that he has a similar experience to me working in my office.   After signing in, he’ll work an eight-to-twelve hour shift with the same nurses, therapists, and techs he’s worked closely with for the past three to fifteen years.  New faces get assimilated into an experienced team quickly, because he’s working side-by-side with them, watching their performance. He knows Lab Tech David is the best “sticker” on old-lady-veins this side of Interstate 55, so that’s who he taps to draw the blood on elderly Mrs. Jones.   Registered Nurse Mendoza is compassionate, gentle, and bilingual, so she’ll work with the Latina woman coming in for a sexual assault evaluation.    Registered Nurse Miller is new and not very experienced with chest pain patients, so letting her monitor heart rhythms isn’t a good thing for her to solo yet.   However, he’ll have an opportunity to mentor her today as they work closely together treating Mr. Aziz, who’s come in with chest pain.   Dr. Leap sees quickly what’s going well and what’s not – because he’s on site with his team, forming rapid assessments of the team’s skills and performance.  He can train or mentor new or inexperienced staff in the hands-on way most of us learn best.  Most importantly, he can intervene if things aren’t going well for his crew.

Money and hours are certainly paramount considerations in the decision of physicians to pursue or abandon inpatient responsibilities.  However, for the pediatrician who wants to treat her patients in the local hospital, we need to make the rest of the hospital as responsive to community physician leadership and ideas as Dr. Leap finds his emergency department.

Suzanne Berman is a general pediatrician in private practice in Crossville, Tennessee.   Her family works, lives, goes to school, worships, and buys stuff from Walmart all within the 38555 zip code.