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
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.
21 thoughts on “Why Can’t Pediatricians Prescribe Medicine Over the Phone?”
Excellent essay. It can be difficult to communicate to an upset parent why it is important to come to the office, but I think you have said it as well as it can be said.
I love this so, so much. This explains so well why you can’t phone in prescriptions without evaluating the children. The only thing I don’t like is that you offer to write off the cost of the office visit, which is noble and would be very much appreciated by most parents, of course. It is my opinion, however, that you shouldn’t give away your services without knowing that there is a documented financial need. You deserve to be paid for your services, especially since you are doing exactly the right thing by your patients. It is hard for me to pay for my four children’s medical care, but it is something I gladly pay for and did even before I understood how hard it is to make a living as a pediatrician.
Wow, what a wonderful post, great message. You said it all so clearly and eloquently. Thank you.
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That is the most eloquent, insightful and accurate answer to one of the most problematic questions we face as practicing pediatricians. Great job!
Very well said, and most of this applies equally well to internal medicine. We also can’t ignore the economics; both internists and pediatricians are paid only for face time with a patient and not for any other care, whether it be paperwork or phone work. Not only is phone medicine often bad medicine, but it can be economically devastating to doctors.
Thank you for articulating such an important issue in
today’s pediatric care.
Very nice post. You hit the nail on the head. Keep up the great work.
Let me tell you a true story: My late husband, (the good pediatric doctor) was not home, when the friend of a friend called, requesting that he call in antibiotics for her (presumptive diagnosis of UTI). I (the evil pediatrician), said no, she should call her own (adult!) doctor, who had not returned her calls (surprise!), and that he had called in antibiotics, for the UTI, the week before. She said she was leaving for Europe the next day. I said go to the ED – I (the evil doctor) was not going to call them in, and that the good doctor was not going to be available.
Two weeks later, there was a message on my answering machine, reiterating how angry that she had been, but that she had gone to the ED, where the diagnosis of renal carcinoma had ultimately been made.
Veterinarians get this ALL the time. Most common complaint “my pet has a UTI, I need antibiotics immediately.” UTI turns out to be: cushings disease, renal failure, diabetes, etc etc…. but until a bad outcome happens to them, the client just views me as the greedy evil vet who wouldn’t prescribe over the phone. *sigh*
Veterinary medicine: different species, same song and dance.
No, I really need to listen to your dog’s chest because kennel cough is only one of the many Ddx I think of when I get a call about a coughing dog. And your dog cannot tell me his recent activity or how he feels.
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Well said. Keep writing…
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Good article, but I’m a little disappointed that one of the reasons was not “Because 80-90% of Ear Infections will never require an antibiotic and will resolve spontaneously”
I personally find the concept of prescribing antibiotics over the phone irresponsible.
Hi Dr. TP,
I didn’t specifically speak to that point (which is an excellent one, by the way). My colleague Dr. Lessin addressed
the overuse of antibiotics for ear infections in a separate post.
While I did start with an ear infection example — one I thought most parents could relate to — I was trying to describe why I don’t like to phone in any medications — not just antibiotics. Parents also have requested that I phone in Zofran for vomiting kids and hydrocodone for a twisted ankle — I won’t do those things either. To your point, the broader explanation I could have made better is: the medication that parents are requesting often really isn’t that helpful anyway. Vomiting kids get better with oral rehydration, not antiemetics, and ankle sprains don’t need narcotics — which I can’t phone in even if I wanted to.
Thanks so much for your comment!
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