Unplugged from the EMR: Now what?

By Suzanne Berman, MD

The surgical metaphor often used for home improvement is “a face lift,” but our thirty-year-old house needs a quadruple bypass and liver transplant. Because it’s going to be so dusty and disrupted, we opted to temporarily move out. Two weeks ago we moved to a quiet rental house in the country, where we can watch fabulous Tennessee mountain sunsets and wake up to the sound of cardinals singing.

The price of solitude is something of a challenge: no cell phone service at our home. Neither my husband’s AT&T phone nor my Verizon service gets any solid bars at our new house. We’ve arranged to get Internet service, but the cable guys haven’t come out to our home yet. We’re not quite 19th century, though, as we have a functional land line.

So last Saturday, on call, I had just returned from a morning at the office to my home (now a 25 minute commute rather than a 10 minute one) when I received a call (land line, of course) through our answering service. A mother apologetically confessed that her daughter was about to leave for summer camp but had just run out of her routine medication. Would it be possible for me to call in a refill?

“No problem,” I said. Although I almost always decline to call in new medications over the phone, refills for established medications are different.

This young lady was well known to me, as she’s been my patient for about 8 years now. Her medical issues are familiar to me without having to look at her chart, and her problems are well-controlled on her current medication. Indeed, I didn’t want her going out to camp without her prescription. After confirming the pharmacy with mother, she thanked me, and I hung up.

…And about two seconds later, I realized I wasn’t sure of the dose of the medication. This particular medication is often used in both 20 mg and 40 mg preparations, and while either dose would probably work for this young lady, I wanted to be sure to refill her usual dose.

Now I had on my hands, for me, a relatively unusual problem. My lifelong geek tendencies made me an early adopter of an electronic medical record (EMR). I can log in securely from home over the Internet, call up the child’s chart, and double-check the dose myself. But stuck at home without Internet service, I was clearly going to have to find a creative solution to this problem.

Maybe I can call the mom back. Unfortunately, I didn’t ask for her number while I had her on the phone. My caller ID read our answering service’s number, not the mother’s;

unfortunately our answering service doesn’t record the number of callers unless they have trouble reaching the physician quickly.

Well, I’ll call the pharmacy. They’ll have her previous prescriptions and can confirm the 20 mg vs. 40 mg question. Clearly, I should have thought of that initially. “No problem,” I muttered aloud, while wishing that the cable guy had come last week as expected.

And I realized I didn’t have the number for the pharmacy, a chain drugstore in a neighboring county. Our phone books were still buried in some packing box. Aha, I can look it up on the Intern…..uhhhh, no I can’t.

I considered getting in the car and driving to the office. 50 minutes just to get a phone number? No, surely I could find another way.

I started calling my co-workers, who have the same ability to look up charts from home as I do. Maybe I could cadge a favor from them. No answer at one number. Oops, don’t have the current number for colleague #2. The third answered her cell phone, but alas, she was in the grocery store shopping with two small children. And frozen food. Could she call me back in, say, an hour?

Hey, I can do this! Call the local branch of the pharmacy! They could give me the number to the other pharmacy. Or I could even give them the prescription, and they could send it to the branch pharmacy! Woohoo!

The pharmacy tech couldn’t enter the prescription for me because I didn’t have the patient’s date of birth handy (!), and “it would take three hours to send it to the other pharmacy” (when it takes me thirty seconds to send it electronically from my office to either pharmacy?). I did, however, get the number for the other pharmacy.

Which I called — only to get an endlessly looped recording, without the ability to leave a message at the pharmacy. “Press 8 if you are a doctor’s office,” an anthropomorphic impossibility, but I complied. After a few clicks, it looped back to the main menu, “Thank you for calling Quik-Drugz. Press 8 if you are a doctor’s office…”

This poor girl, stuck at camp without her meds! I ended up getting the car with my smartphone and laptop, driving around about 15 minutes until I got a steady two-bars. I pulled over to the side of the road, the spring heat baking through the window, my blinkers flashing, while I fired up my Internet connection…. logged in…. found her chart (aha, only 20 mg, not what I would have guessed)…. and sent the prescription to the pharmacy, yes!

And then got another page. “Dr. Berman,” the answering service explained, “we’ve been trying to reach you for a while…”

Fortunately, the next call was a discussion of high fever in a toddler. We reviewed fluid intake, ibuprofen dosing, and what to watch for – much less complicated than having to call in a refill.

I guess you can take the geek out of Internet range, but you can’t take Internet out of the geek.

Dr. Suzanne Berman is a practicing pediatrician in Tennessee. She recently celebrated 17 years of marriage to fellow geek Robert Berman, MD, who continues to impress her with his Holy Grail quotations.

Does My Child Need Vitamins?

By Jennifer Gruen, MD

This is one of our most commonly asked questions at well-child checkups.

Vitamins and minerals are important elements of the total nutritional require­ments of your child. Because the human body itself is unable to produce ade­quate amounts of many vitamins, they must be obtained from the diet. The body needs these vitamins in only tiny amounts, and in a balanced diet they are usually present in sufficient quantities in the foods your youngster eats.

Breast fed infants need vitamin D supplementation until they are able to eat foods containing at least 400 IU of vitamin D a day. Children in homes with well water may need a fluoride supplement to support dental health — ask your dentist or us for a prescription if your child does not consume fluoridated water elsewhere, such as school or daycare. Otherwise, in middle childhood, supplements are rarely needed.

For some youngsters, however, we may recommend a daily sup­plement. If your child has a poor appetite or erratic eating habits, or if she con­sumes a highly selective diet (such as a vegetarian diet containing no dairy products), a vitamin supplement should be considered.

These over-the-counter supplements are generally safe; nonetheless, they are drugs. If taken in excessive amounts (in tablets, capsules, or combined with other supplements), some supplements — particularly the fat-soluble vita­mins (A, D, E, and K) — can be toxic. Scientists are finding that in some special situations and diseases, vitamin supplementation can be an important con­tributor to health.

However, so-called megavitamin therapy or orthomolecular medicine — in which vitamins are given in extremely large doses for conditions ranging from autism to hyperactivity to dyslexia — has no proven scientific validity and may pose some risks. Vitamin C, for example, when consumed in megadoses in hopes of undermining a cold, can sometimes cause headaches, diarrhea, nausea, and cramps.

As much as possible, try to maximize the vitamins your child receives in her regular meals. Click here to read more about some of the vitamins and minerals necessary for normally growing children, vitamin rich foods and recommendations for specific supplements.

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

She has a fever, her temperature is 99.2. Is It Normal?

By Jesse Hackell, MD

Photo Credit: Gary Ellis

It is Normal?

Every day, parents bring their children to the pediatrician’s office with complaints that something about the child is not “normal,” whether in terms of temperature, sleep patterns, appetite and food intake, elimination of urine and stool, and a whole host of other bodily functions. I spend a good part of many visits helping parents understand just what is, and should be, meant by the word “normal.”

Body Temperature

We have all grown up with the concept that the “normal” body temperature is 98.6 degrees Fahrenheit, right? Heck, it even says so on the old style glass thermometers, with a nice little arrow pointing right at 98.6—not that many of us use those glass thermometers any more (and no one should be using ones which contain silver-colored mercury) since ear and temporal thermometers have become so much more available and affordable in recent years.

In fact, the normal body temperature is not one number, but a range, generally felt to vary between 97 and 100.4 degrees. And it varies predictably with the time of day as well. Called a diurnal (from the Latin for day) variation, we reach our lowest temperature in the early pre-dawn hours, and our temperature peaks about twelve hours later, in the late afternoon. This variation is hormonally controlled, and while the times of the peaks and valleys can be altered (by changing sleep patterns, for example), this variation, and range of normal temperatures is characteristic of all humans.

So not only (as my colleagues have previously discussed) is fever not something to be feared, it is also something to be careful about even diagnosing. Consider that the temperature of a healthy, “normal” child might vary as much as three degrees Fahrenheit from the daily low to the daily high. And remember that, much more relevant that the number on the thermometer is the way that your child looks and acts.

What about sleeping patterns?

Is it “normal” for a baby to sleep eighteen hours out of twenty-four? Or for a toddler to seem as if he can get by on eight hours at night plus a couple of power naps during the day? The same answer applies to sleep as it does to fever—there is a wide range of what “normal” children require in order to function normally.

And therein lies the true answer: A child is getting enough sleep if he or she is able to be awake and functioning normally for blocks of time during the day, if he or she is not always yawning or drowsing off during activities, and if the mornings are not a struggle to get the child awake and moving in order to get the day started. Look at your child’s general alertness—that will give the best clue as to whether or not the amount of sheep he or she is getting is adequate.

Normal Food Intake

It is very hard to define a “normal” amount of food and nutrition intake. Different children have different metabolic rates and activity levels, and children do not grow at the same rate every day. No one—not the doctor, not the parent, not the grandmother—knows better than a child just how much nutrition a given child needs on a given day. And normal children will not starve themselves—they will choose and eat the foods that their bodies tell them are needed for growth.

Of course, they might naturally choose sweets or “junk” food, but I presume that, as parents, we will offer our children choices consistent with good nutrition, and allow then to choose types and amounts of foods from that selection. A parent’s job is NOT to get a child to eat; rather, it is to provide nutritionally sound choices from which the child can select those foods which his or her body needs at any given time.

Once again, the same thing holds for bowel movements, especially in the newborn and infant period.

There is no single “normal” frequency for an infant to have a bowel movement.

The pattern will depend on age, feeding and the infant’s own physiology, but, in general, as long as there are bowel movements at least every two to three days (although it can be longer in an exclusively breast fed infant), and most importantly, as long as they are soft and do not cause the baby discomfort when being passed, a baby will move his or her bowels when it becomes necessary. (This is not necessarily true as a child gets older, when some may hold their stools for prolonged periods, often out of fear of discomfort or out of hesitation to use a toilet; any signs of difficulty in defecation in an older child should be discussed with your child’s pediatrician.)

As in so much of pediatrics, what is “normal” can often best be defined by what is working for a particular child, and not by comparison to what other children are doing or experiencing. I cannot emphasize strongly enough that if your baby or child is happy, thriving, comfortable and growing, and is able to function normally, the chances are good that whatever he or she is doing with regard to temperature, sleeping, eating or eliminating is “normal” for him or her.

Listen to and watch your child—they are really good at letting you know if things are going well or not.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

Related articles

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• Are High Fevers in Children Dangerous? (survivorpediatrics.wordpress.com)
• Many Parents are Afraid of Fever. Don’t Be. (survivorpediatrics.wordpress.com)

Do Parents and Pediatricians Need to Reconsider How Children Use Technology?

By Brandon Betancourt

Dr. Claire McCarthy from  Children’s Hospital of Boston published a very interesting blog post regarding the need for “parents” and “pediatricians” to reconsider the way we approach modern technology with our children.

Coincidentally, my wife (a pediatrician) and I (not a pediatrician) discussed a similar issue just this morning. We were discussing how much time we should allow our 12 year-old daughter to spend texting with her friends.

I suggested we should not be too concerned with how much time she spends texting (as long as it doesn’t interfere with her responsibilities) because it is now the way children communicate. It is their thing now, just like it may have been previous generations thing to spend hours and hours in front of a TV screen or another generation’s thing to spend hours and hours talking on the telephone. As a pediatrician, my wife wasn’t convinced with my point of view.

Dr. McCarthy acknowledges that pediatricians frown upon “screen” time. She says:

We stress the 2-hour limit to help prevent obesity. We warn about Facebook depression, exposure to violence and sex, cyberbullying and online predators. We talk about how texting can keep kids up at night and how video games can contribute to ADHD.

And although she continues to support this message, Dr. McCarthy says that when we just focus on the negative, parents and pediatricians may miss two important points which are: technology is not ALL bad and, as she puts it, for better or worse, digital media is here to stay.

If we are just negative, we may miss the opportunity to inform the discussion. Pediatricians may miss the opportunity to guide children and families in the best uses of technology. Someone else will step in and do it, someone who doesn’t understand child health and development the way pediatricians do. And kids aren’t going to want to talk to their parents about what they are doing online if they think that their parents’ only response will be disapproval.

I like Dr. McCarthy’s call. She is challenging pediatricians (and parents as well), “to meet kids where they are” and start becoming more connected their world.

It’s hard to inform a discussion about something you don’t know about. So pediatricians and parents should explore the Web and see what’s out there. Do health searches; see what pops up. Find sites and applications that you like and can recommend. Talk to kids about how they use technology—learn from them. Check out Facebook and Twitter and YouTube. Consider using social media yourself.

To read Dr. Claire McCarthy’s post, you may click here 

As a pediatrician, do you think McCarthy has a point? Is there anything you’d disagree with? What about as parents? How are you dealing with “screen time?” Do you tend to have a more conservative view, like my wife, or are you more like me? We’d love to hear your thoughts.

Brandon Betancourt is medical practice administrator. He lives in the western suburbs of Chicago, has three children and admits to being addicted to his iPhone. Brandon regularly blogs at PediatricInc.com. You can follow him on Twitter @pediatricinc.

Anticipatory Silence: Florida Law Prohibits Freedom of Speech in the Physician’s Office

By David Sprayberry, MD

Wow. I am flabbergasted and disappointed by what has happened in Florida and what is being advocated now in other parts of the country.

For those who may have missed it, Florida has passed a law that says that a pediatrician is not allowed to ask a parent if there are guns in the home. This bill was a joint effort by the National Rifle Association and the Florida Medical Association. Proponents of the bill apparently fear that the questions that physicians ask in the setting of a confidential medical visit will be used against them by the U.S. government at some point in the future.

Let me preface the rest of this discussion by saying that I support the second amendment and the right of Americans to bear arms. My objection to the Florida law is its interference in the patient-doctor relationship.

Former Georgia congressman Bob Barr has written a blog post criticizing pediatricians for asking the question and proposes that pediatricians should concern themselves only with recognizing and treating illness, rather than preventing illness.

As a practicing pediatrician who politically falls on the spectrum between libertarian and conservative, I believe that the government should interfere with citizens’ personal lives as little as possible. I believe that law and order, the common defense, and the provision of public necessities, such as the highway system, should be the primary focus of our government.

I believe the Constitution, with its amendments, is one of the greatest achievements in human history.

I believe the Constitution should be respected by our congress and by our courts and that alterations to our constitution should only be made by the prescribed constitutional process and not through activist judges.

Bob Barr claims to be a libertarian, yet his support for this misguided Florida law reveals him to be a libertarian in name only. A true libertarian would not advocate for the protection of one constitutional right (the Second Amendment) by unconstitutionally limiting another (the First Amendment).

A true libertarian would not support governmental interference in the doctor-patient relationship, but would recognize the importance of confidentiality in that relationship. A true libertarian would say that what a physician discusses with his or her patients is none of the government’s business.

Bob Barr makes a number of ridiculous statements in his blog on this issue, such as the assertion that you will see your pediatrician for an illness and be asked if you have a gun.

He also suggests that pediatricians ask children to snitch on their parents with regard to the presence of guns in the home.

If he had been to a pediatrician’s office in the last 20 years, he would be aware that pediatricians are so busy making sure they cover all the things they are supposed to cover that they really aren’t going to waste their time interrogating parents and their children about guns.

Pediatricians may counsel about gun safety verbally or, more likely, in written format, because prevention of injury is part of what we do. We will also warn about the dangers of certain sleep positions, we will advise the use of helmets when biking or skating, and we will counsel about water safety.

Apparently though, Barr also objects to any discussion of safety since he doesn’t want pediatricians talking about pools either. For his blog on the topic, go here.

Barr further asserts that all pediatricians believe that no one should own a gun. He states “Apparently, the Hippocratic Oath taken by these pediatricians includes a footnote to ignore the Second Amendment guaranteeing Americans the right to own a firearm.”

Mr. Barr neglects to acknowledge that this legislation is an infringement to the First Amendment’s guarantee of freedom of speech and also fails to recognize that pediatricians are not agents of the federal government (although I would love to be able to take advantage of the federal holiday schedule).

Leaving the fact that Barr’s position on this issue reveals him to be just another politician who will say whatever he thinks will bring him popular support, let’s move on to the question of whether a pediatrician should only be concerned with treating disease and not preventing it, as Barr asserts in his blog.

This logic, if applied to medicine in general, would be catastrophic. Vaccines, probably the single greatest medical achievement in history, would not exist. Countless multitudes of people would have already died or been permanently disabled just since the advent of the modern vaccine era in the last century if vaccines had not come to be. Countless more would never have been born to begin with, since one or more of their parents would not have been able to conceive them. You and I might not be around to even have this discussion.

According to the CDC: Before polio vaccine was available, 13,000 to 20,000 cases of paralytic polio were reported each year in the United States. Before measles immunization was available, nearly everyone in the U.S. got measles.

An average of 450 measles-associated deaths were reported each year between 1953 and 1963. If vaccinations were stopped, each year about 2.7 million measles deaths worldwide could be expected.

Before Hib vaccine, Hib meningitis once killed 600 children each year and left many survivors with deafness, seizures, or mental retardation. Since the introduction of conjugate Hib vaccine in December 1987, the incidence of Hib has declined by 98 percent.

Prior to the licensing of the chickenpox vaccine in 1995, almost all persons in the United States had suffered from chickenpox by adulthood. Each year, the virus caused an estimated 4 million cases of chickenpox, 11,000 hospitalizations, and 100-150 deaths.

Besides the overwhelming success of vaccines, there are numerous other successes achieved by practicing preventive medicine and providing anticipatory guidance (anticipatory guidance is the practice of providing advice to parents to help avoid injury, illness, and other negative events that may compromise the health of children).

Since pediatricians began to recommend putting babies to sleep on their backs, cases of Sudden Infant Death Syndrome have declined by 60%-75%. Since removal of lead from paint and gasoline, cases of true lead toxicity in the U.S. have decreased dramatically, except in certain limited geographical areas.

Preventive medicine is the cornerstone of pediatrics, particularly in the United States of America. It is far better to prevent illness and injury than to treat it once the damage has been done.

Perhaps I should frame this in a way that a politician can understand: Is it better to do damage control once your extramarital affair has been discovered or never have the affair to begin with? Is it better to defend yourself before a grand jury regarding the funds that you misappropriated or is it better not to misappropriate the funds to begin with?

If you would rather that your state and federal governments not interfere with what you can say to your doctor and what your doctor can say to you, please let your representatives and senators know that this kind of intrusive legislation is not acceptable.

Our politicians need to know without a doubt that passing laws such as these will be detrimental to their careers.

Dr. Sprayberry is a practicing pediatrician and believes there is more to medicine than shuffling patients in and out the door. To read more about Dr. Sprayberry’s medical trips to Kenya, visit his blog, Pediatrics Gone to the Dawgs.

Related articles

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The Right Level of Care for the Right Illness

By Jesse Hackell, MD

The phone call came in through the answering service around 7:00 pm. “She’s four years old, Dr. Hackell, and she has a fever of 102 since this afternoon. Should I rush her to the emergency room?” Aside from the fact that I was still in the office, seeing patients until 8 that evening, as we do routinely in our office, I began thinking about the difference between an emergency, an urgent matter, a worrisome problem and an ordinary medical illness or question.

This is not a trivial distinction to make when one considers the reasons that parents seek health care for their children, and it has a great impact as well on the burden that society faces in providing, and paying for, health care.

An Emergency

An emergency is a condition where there is an immediate threat to one’s life or limb, a situation where, in the absence of prompt medical attention, there is a risk of serious, permanent or even fatal injury resulting. Examples are many, and could include a heart attack, head trauma with loss of consciousness or skull damage, prolonged seizures or asthma with respiratory distress.

An Urgent Matter

An urgent matter is not so easily defined, but might be considered a medical condition which is not life-threatening but which requires medical care to avert progression to a more serious condition which could become life-threatening. One might think of pneumonia, less severe asthma attacks, hives, persistent vomiting, and other similar examples. A worrisome problem is something which is clearly an illness, which may be causing discomfort, and which could, in theory, represent the onset of a more serious matter, but which at the moment is clearly not affecting a patient’s ability to breathe or otherwise function and interact with others. This category might include fevers, coughs, pain in the extremities, pain on urination, headaches and so on.

Ordinary Medical Issues

And finally at the bottom of the list are the ordinary medical issues, best exemplified by the itchy rash of poison ivy, pinkeye, allergies and cold symptoms.

Why does this distinction matter?

It is inarguable that conditions should be treated at the facility best able to care for the patient in an efficient and cost-effective manner. Care in emergency rooms is many times more expensive than the same care delivered in a physician’s office, and in cases other than true emergencies, as defined previously, equally effective.

Consider the child with abdominal pain, fever, loss of appetite and vomiting.

When that child is seen in a pediatrician’s office, especially the child’s “medical home” where she is known to the doctor and staff, she will be seen and carefully examined, maybe have a urine sample and blood count done, and observed for the signs that her illness might represent a true emergency such as appendicitis, in which case she would be admitted to the hospital for either more testing or for surgery.

But more likely, the results of the evaluation will be normal or non-specific, and she will be felt to have a stomach virus or cramps, and be sent home with appropriate management instructions and an admonition to return or call if more worrisome symptoms develop.

Contrast that with the same child taken to the ER.

The hospital charges for ER use are high, as are those of the ER physician. In most ERs, the child is more likely to have a battery of blood tests done, as well as an expensive CT scan of the abdomen—again, seeking to determine the presence or absence of appendicitis. Even if the child turns out, in the end, to have a stomach virus, the costs incurred in getting to that diagnosis will be vastly higher than those for the child seen in her pediatrician’s office. In addition, the time expended in the ER is likely to stretch into hours; rare, indeed, is the office visit, even with a period of observation, which exceeds an hour in duration.

While no reasonable pediatrician would attempt to manage a life-threatening condition in the office, we do see urgent conditions every single day. We take care of kids with asthma who come in wheezing, we see children who have had seizures from fever, we evaluate injuries which might break bones and we manage vomiting and dehydration—these “urgent” conditions are often able to be managed quickly, efficiently and effectively in the same offices where children get their routine examinations and immunizations.

We insure that urgent matters are attended to promptly, compared to an ER where the asthmatic child might wait for hours until after the heart attack or multiple trauma patients are seen, especially on busy evenings.

Pediatrician’s office are often a more friendly environment.

Finally, the pediatrician’s office is a place known to the child, often more child-friendly than a large, noisy and busy emergency room, so the child is likely to avoid having an already scary situation be made even more frightening by the bustle of an unfamiliar place and unfamiliar faces.

Worrisome conditions are those which do not need to be seen in an ER, either, especially at night.

We all know how kids have a knack of getting sick at night, and on weekends and holidays. But it is important to decide whether the condition is a something that can and should wait until the next morning, to be seen in the child’s regular doctor’s office, as opposed to immediately running out to the nearest hospital, often giving everyone in the family from the child on up a long, miserable night in the ER.

With more and more pediatricians adding evening and weekend hours, it is rarely the case that a sick child will need to wait much more than twelve or so hours before being seen and evaluated. Life-threatening emergencies should always go to the ER, and I would encourage parents to be over-cautious in determining what they might be worried about as an emergency.

But at the same time, with a child with a simply worrisome condition, observing the child and thinking about how ill he or she appears is the first step to deciding whether or not to “rush” to the ER. A phone call to the pediatrician can also help a parent decide the degree of urgency represented by the child’s symptoms. Many times the child with a fever or an injury looks and acts good, and can be made comfortable at home until the doctor’s office opens in the morning. This actually will make the illness easier on the child, and enable him or her to be seen in the most familiar place, reducing the stress on all concerned.

It will also generally be more cost-efficient.

There is no doubt that the American health care system is in a financial crisis, given the large proportion of our national wealth consumed by health-care services. Pediatricians certainly do not advocate skimping on health care for financial reasons; in fact, the often-expensive preventive care which is our special interest may cost money upfront, but the payback over the years in dollars saved (and improved outcomes as well) is well documented.

What we do seek to encourage is the most efficient and cost-effective use of health care dollars, in order that we, as a nation, can get the biggest bang for our buck. Making sure that our children get the level of care appropriate for the degree of their illnesses is just one step in that direction.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

Related articles

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How Should the Doctor Know?

Written by Dr. Nelson Branco

Last week, a family asked for my opinion on whether they should have a third child. Truthfully, my first instinct was “How should I know?” but of course, that’s not what I said. It’s a fair question, considering that I have three kids myself, and I know a thing or two about families and kids. But it’s a very personal decision, and one that this couple was obviously taking very seriously. After spending a few minutes giving them the most thoughtful answer I could come up with, I went on to the next patient and the next set of questions.

But the moment stuck with me because it illustrated in a concrete way that I have a special role in the lives of my patients and their families.

When I meet with parents-to-be for a prenatal visit, I tell them that I give advice, and they make decisions. I am full of advice and opinions (ask anyone) but ultimately they have to decide on bedtimes, rules, discipline, sleep training, diapers, feeding, and the many decisions to be made when you’re a parent.

When I was a kid, there were a few people whose opinion was sought out and respected because of who they were – doctors, priests and teachers. Others had to earn respect on their own merits. Times have changed, and I live in a different community than the working-class immigrant community where I grew up.

My opinions and advice have to stand on their merits, and I have to earn the respect and trust of my patients and their families.

I wouldn’t have it any other way, and neither would your pediatrician, I’m sure.

I don’t live in a particularly small town, but our community is small enough that I’m frequently recognized by patients or parents. I enjoy it, but my kids sometimes complain – “Wherever we go, you see one of your patients!”. It’s not like being a rock star, but I do have to mind my manners in public, and I’m sure to be asked to examine at least one rash if I venture out to a school event or the farmer’s market.

A few weeks ago, that didn’t work out so well. Riding home on my bike, I passed two of my patients standing on their front porch. I waved, which meant that when the the Prius (quietly) came around the bend, I didn’t have my right hand on the brake lever. Anyone who has ever ridden a bike can predict what happened next.

Too much front brake sent me flying over the handlebars.

Of course, I was wearing my helmet so I can now speak with even more authority about the importance of wearing one. Unfortunately, the helmet didn’t stop me from breaking my elbow (radial head). The person driving the Prius stopped immediately to see if I had survived. This being Marin County, the herbs and potions capital of California, she immediately offered me Arnica to apply to my wounds. I deferred. Didn’t want to delay the x-ray and pain medicine that I knew were in my future.

So the doctor became a patient, and I spent a few weeks explaining to parents why I am examining their children one-armed. I know that they appreciate that I am there, and to be honest I never considered staying home from work – who would tease me about my bike crash otherwise?

Last month, my colleague Dr. Sprayberry posted “Why Your Doctor Chose to Be Your Doctor.”  He talked about the sacrifices medical students and residents make to become doctors, and how much strain that can put on us personally, and on our families. We do it “to help people” as he puts it, but it’s much more than that. I go to work each day to listen, advise, assist and amuse. I know that I am a part of my community and of my patients’ lives because they are a part of mine. I hope you can say the same about your job. Like I said, I wouldn’t have it any other way.

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.

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Six Reasons You May Want to Bring Your Child to the Pediatrician’s Office Instead of a Retail Based Clinic.

Written by Richard Lander MD

Why should I bring my child to the pediatrician when he/she is sick? It is so much easier to run over to the local retail-based clinic (RBC) at the pharmacy where there is lots of parking, I don’t need an appointment and while I’m there I can pick up tissues, milk and medicine. Right?

Here are six reasons why going to a RBC may not be in the best interest of your child’s health.

1 – Most RBCs are not Staffed with Board-Certified Pediatricians

Your child will probably be diagnosed and treated by a nurse practitioner or physician’s assistant. Imagine that you are concerned about your child and therefore a little distracted and forget to mention that your child has allergy to an antibiotic. This could have a bad outcome. If you are at your pediatrician’s office, that allergy information is kept in your child’s chart.

2 – You Can’t Call The RBC in the Middle of the Night

Now imagine that your child’s condition worsens at midnight. The RBC you visited earlier is now closed and so you can’t ask for further advice. On the other hand, had you called your doctor earlier and then required additional help later in the evening, you would be able to receive consistent medical advice because your doctor or a covering doctor is on call 24/7. The American Academy of Pediatrics has always stressed the importance of continuity of care. It’s what I want for my children; it’s what I want for your children.

3 – RBCs Have Age Restrictions

Many RBCs have an age below which they will not treat a patient. What will you do if two of your children are sick — take one to your doctor and the other to the RBC?

4 – RBCs Can’t Handle Complex Medical Issues?

Worse still, the RBC cannot deal with complex medical issues. If you visit the RBC with a problem that is beyond the scope of their training and knowledge, they will tell you to see your doctor or send you to the emergency room.

5 – RBC Provides No Continuity of Care

Let’s think about vaccines. Your child needs a flu vaccine as well as one or two other immunizations. Many of the RBCs are only prepared to give the flu vaccine. If you are receiving the flu vaccine at the RBC and all other immunizations at your pediatrician’s office, no one will complete your [child’s] vaccination record. Again this speaks to a lack of continuity of care. This fragmented record keeping could cause trouble in the future.

6 – An RBC’s Not Your Medical Home

Your pediatrician’s office should be your child’s medical home. Your pediatrician has cared for your child’s physical and mental well being since birth. At your pediatrician’s office you received vision and hearing screening, and we assessed your child’s fine and gross motor skills. Your pediatrician has checked for autism and ADHD, asked you questions relating to your child’s growth and development and if there was a concern, and addressed it. When a behavioral problem at school or home arose, it is your pediatrician who thought about the possible medical conditions that could cause these behavioral changes. Will your RBC help you with your child who is crying out for attention secondary to a new baby at home or to parental discord? Will your RBC talk to your teenager about depression, alcohol, drugs or tobacco use? If your child has a GI problem, a broken arm, a heart condition or a blood disorder, will your RBC recognize the problem and send you to an appropriate specialist? Would you want the recommendation of a competent specialist to come from your RBC or from your doctor who knows you and your family’s medical history?

Your pediatrician provides your children with vaccines after they have looked at the medical research. He/she does not give vaccines because a corporate entity (RBC) made the decision to do so. Your pediatrician went to medical school for four years and then did a pediatric residency for an additional three years and continues to both attend medical conferences and read the medical literature to make ensure that he/she remains current and ahead of the curve. One of the national RBC chains has the tag line “You’re sick, we’re quick.” Is that the kind of medicine your loved ones deserve?

 

Dr. Lander has been practicing pediatrics for 32 years in New Jersey and is the immediate past chairman of the American Academy of Pediatrics Section on Administration and Practice Management.  He says if he had to do it all over again he wouldn’t hesitate to be a pediatrician.

Docs not tech savvy, or tech not doc savvy?

Written by David Sullo MD., FAAP

I recently wrote a post about why your pediatrician may not be using an electronic record. Uptake has been slow largely because doctors believe their daily work would not be made significantly easier or more effective with the current systems available. Furthermore, if they do invest in one and it is not a good marriage, it is difficult to then switch systems.

The government has taken the top-down approach to this issue, otherwise known as the “let’s throw money at the problem” approach. Physicians that can show what is termed “meaningful use” of an electronic record are eligible for financial reimbursement from the feds. This has led to some unintended consequences. First, physicians are chasing that money by purchasing systems that may not meet their needs, because time is of the essence (the program expires). Second, EMR developers are focusing on the government’s criteria for “meaningful use,” at the expense of other functionality. This will lead to some very bitter doctor’s offices in about 3-5 years, when the money runs out and they don’t like the EMR they chose. However, the government will have very nice graphs about how their program increased EMR use in physician offices.

My belief is that the government should have taken a bottom-up approach to this issue. A standard database for medical information needs to be deployed. Electronic records are basically a large database. However, each company creates this from scratch, and because of this they are all speaking different languages. This makes it difficult to send data from one system to another, and even more difficult to switch systems within a practice if your first one is a lemon. A good analogy is the Internet. Webpages are written in a standard language (HTML). No matter whether you use Internet Explorer, or Firefox, or Chrome, a given webpage looks the same. Now imagine if this were the case in the medical field. If all EMRs had to use a standard database, it would lead to several things:

First, the communication problem between EMRs would be solved, because they would all be “speaking the same language.” No more costly interfaces.

Second, it would make it infinitely easier to switch EMRs. This would remove one of the main barriers to adoption that currently exists. Just as I can easily ditch IE and switch to Firefox and the CNN website still looks the same, I would be able to ditch one EMR for another without losing my patient’s data.

Finally, because of this ease of shifting from EMR to EMR, developers would have to actually compete on function. I think this would be the development that would allow electronic records to finally hit the mainstream. I have often wondered what an EMR designed by Apple would look like. If the government would remove barriers to competition, rather than try to legislate EMR into existence, we might indeed someday have “an app for that.”

Dr. Sullo is a pediatrician at Genesis Pediatrics in Rochester, New York. He admits to having gone to computer camp in 5th grade when everyone else was playing baseball, and is an “Apple Fanboy.” He does his best to offset the geekiness by throwing in some winter backpacking.

Many Parents are Afraid of Fever. Don’t Be.

Written by: Kerry Frommer Fierstein, MD, FAAP

In a recent article the American Academy of Pediatrics reviews the facts and fiction that surround fever in children and reminds nurses and pediatricians to better educate parents about fever.

Important fever facts:

The following information does not apply to infants under three months of age for whom you should contact your pediatrician urgently for any temperature of 100.4oF (38oC) or higher.

• There is no “normal” temperature. 98.6 is an average and many children will normally run a little higher or a little lower. In addition, throughout the day, a given child’s temperature will vary by as much as a full degree.
• Fever can be helpful in fighting infections. Fever slows down the growth of viruses and bacteria while activating our immune system.
• Higher fever does not necessarily mean a more seriously ill child. Most fevers, no matter how high, are brief and not dangerous. However, if your child has a fever greater than 101 degrees Fahrenheit for more than 48 hours you should see the doctor to discover the cause of the fever.

Fevers do not cause brain damage or death. Children with fevers above 104 degrees are not at increased risk of problems because of their temperature (the one exception is heat stroke, which usually occurs from over activity in warm weather.) Fevers can cause “febrile seizures” but these types of seizures, though scary to watch, do not cause any permanent effects. Furthermore, there is no evidence that Tylenol (acetaminophen) or Motrin (ibuprofen) use will reduce the risk of fever seizures.

Parents should remember:

• The #1 reason to bring down your child’s fever is to make him/her more comfortable.
• It is not necessary to wake your child to give him/her fever medicine.
• Look at your child, not the thermometer. If your child is drinking, quietly playing, or sleeping, do not worry about fever. If your child looks poorly and is too weak to drink, he/she should be seen by the doctor regardless of the temperature.

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 atPediatric Health Associates, PC, a division of Allied Pediatrics of New York.