Visiting The Pediatrician With Your Teen. What Are They Talking About In There?

Written By Nelson Branco, MD FAAP

As a parent, the teen years can be like a roller coaster ride. Thrilling, fun and scary – and sometimes you just want to cover your eyes and hope it will end soon. Your pediatrician* wants to support you and your family in providing the knowledge and guidance your teen needs to navigate these exciting years.

screen-shot-2016-10-17-at-12-28-48-pmWe are here to educate your teen and monitor their physical, mental and emotional health.

Teen physicals are very different from earlier visits or check-ups.

At a teen visit, we want you to have time to talk to us about your questions and concerns and pass on important information about your child’s health.

Because we want to give teens a chance to talk to us one on one, the parent will be there for some of the visit, but not the whole time. This is so that we can bring up subjects that teens may be shy about discussing in front of their parents.

They need to feel comfortable talking about issues related to their health – it’s time for them to gain some independence and responsibility around diet, exercise, sleep and other health habits.

The time we spend with your teen will be confidential

The pediatrician won’t go over the details of what they talked about. One exception to this rule is when something comes up that makes us worry your teen may be in danger.

If your teen needs help we will find the help they need, and help them talk to you about whatever the issue may be.

After the visit, you should ask your teen what we talked about. It’s a good way to start a discussion about topics that can sometimes be uncomfortable.

Your child may be asked to fill out a questionnaire about their mood and generally how they are feeling.

These questionnaires are important for us to ‘break the ice’ and convey to kids that we are ready and willing to talk about their feelings, especially if they are feeling anxious, down or depressed.

This questionnaire also helps us identify kids who may be having trouble but are reluctant to talk about it.

Insurance companies require us to bill this separately from the visit, but some have decided that this charge should be paid by you as part of your co-insurance or deductible.

Don’t be surprised if you see this noted separately on your Explanation of Benefits (EOB) or bill.

During the visit, your pediatrician will cover a wide range of topics.

We always discuss overall health as well as injuries, complaints or health conditions your child may have. If your child is playing sports we will also ask about family history of heart issues, lung or heart issues while exercising, concussions and past injuries.

We will be talking to your child about their home and school environment and relationships, school performance and goals, and activities, hobbies or sports that they are involved in.

Diet is an important topic, since we want to make sure your child is eating a healthy, appropriate diet and growing well.

We talk about depression, anxiety, mood and social issues with all teens. We all know that the teenage years can be stressful and it’s important that teens have a trusted adult to turn to for help when they need it – we hope to be one of those trusted adults, but also want them to have someone else in their daily life who is there for them.

Drugs, alcohol and tobacco are important topics.

We know that our kids may be exposed to these substances, and a significant number of teens are experimenting with or using nicotine, alcohol, marijuana, prescription drugs or other illegal drugs.

We want to make sure that kids are healthy, safe and making good decisions.

Please remember that your kids are watching and learning about these issues from you.

Think about your own attitudes and use of alcohol and drugs, and make sure you are sending the right message to your teen.

Relationships, gender, sexuality and sex are topics that all teens think about and sometimes struggle with.

Our kids have lots of different sources of information – parents and other adults, school, the media, the internet and friends. Teens need the right information and resources to make healthy choices.

Their relationships with peers – both friendships and romantic – are important for their growth, maturation and happiness. We want these to be healthy, respectful relationships.

From the time your child was an infant we have discussed sleep and screen time. This doesn’t stop in the teen years, but now your child has more control over their digital devices and their bedtime.

We want to make sure that the work, entertainment and social life that is happening on these devices isn’t interfering with school, relationships and sleep.

These visits take a bit longer than checkups for younger kids.

Hopefully this has helped you understand why. Your pediatrician has spent time over the years getting to know you, your family, and your child. Young adults should know that we are here to help them when they are hurt, sick or not doing well.

We also want them to know that we are proud of their good decisions and ready to celebrate their success. Everyone should get off this roller coaster smiling.

*Throughout this article, I’ve used the term pediatrician to mean someone who provides medical care to teens. This can be a pediatrician, adolescent medicine specialist, family physician, nurse practitioner, physician assistant or another medical specialist.


Dr. Branco is a practicing pediatrician at Tamalpais Pediatrics. He works in both the Novato and Larkspur offices. Dr. Branco is very active with the local chapter of the American Academy of Pediatrics and is a member of the AAP Committee on Native American Child Health. He is also an Assistant Clinical Professor of Pediatrics at UCSF.



Why don’t you have separate sick and well waiting rooms?


Written by Suzanne Berman MD. Dr. Berman is a practicing general pediatrician in rural Tennessee.

We’re occasionally asked by families why we don’t have separate waiting rooms for sick and well patients.  It’s a good question, especially given that many pediatric offices are designed this way.  There are several reasons why we chose not to do this.

 What ‘s a “sick” visit vs. a “well” visit?  

The first problem is one of definition.   While some kids are very clearly sick and other kids are clearly well, many of the visits we do don’t fit nearly into one category or another.  Is a depressed teenager “sick” or “well” ?

What about a 4 year old with a possible urinary tract infection?   An infant who’s not gaining weight?  An 8-year-old with belly pain?   A better way to separate the waiting rooms would be a “contagious” waiting room and a “noncontagious” waiting room.


Parents often don’t know whether a child is contagious or not when they check in.  

We don’t expect them to be – that’s our job.   If a child comes in with a new rash, it might be eczema (not contagious at all), chickenpox (very contagious), or ringworm (only very mildly contagious, and certainly not enough to keep them out of school or sports.)   Fifth disease is contagious and causes a rash – but once the rash appears, the child is no longer contagious.

Knowing whether the child is contagious (and how contagious, and for how long) first requires a medical evaluation – and that happens after the child has been brought back, not in the waiting room.

What about siblings? 

We often see double or triple appointments in a family.   If Dad brings in a 6-month-old baby for a checkup (a well visit) and his two year old sister for a cough (a sick visit), what side of the waiting room should the whole family sit on?

We could put the well baby on the sick side (since he’s already been exposed to the two year old’s illness, presumably), or we could put the sick child on the well side (to keep the well baby well.)   There’s no good answer.

And I can’t put a number on the times I’ve seen a well child who was accompanied by a parent who was coughing and sneezing uncontrollably.

It actually can make crowding in the waiting room worse.

Our office’s single large waiting area measures about 20 x 30 feet.   Let’s say we divided it in half, to create separate sick and well waiting areas, each about 20 x 15 feet.

In the summer, when 70 percent or more of our visits are “well,” our patients would be crammed in a much smaller room while our “sick room” would be underutilized.

The exact opposite would be true in the winter months –a crowded waiting room of sick children half as big as it could be.   When we have a single large area, we can make the most of our space; families can sit wherever they wish, near or far away from anyone else in the waiting room.

Parents are sometimes not honest about their child’s contagious condition.

I once reviewed a malpractice case in which the plaintiff contended that the defendant pediatrician didn’t recognize a baby’s sickness. The defendant’s attorney asked the plaintiff’s grandmother (who had brought the baby to the office) whether the grandmother chose the sick or well side.

The grandmother said, “We sat on the well side.”  The defendant’s attorney asked, “If the baby was sick, as you say, why did you sit on the well side?”   The grandmother replied, “Well, she wasn’t very sick at the time – just a little sneezing and cough.  And I didn’t want her catching something from the sick side.”

Honest parents will admit that they’re usually more concerned about keeping their own child away from other sick children, rather than worried that other well children will catch their child’s illness.

Our receptionists don’t want to police the waiting rooms.

Colleagues with separate sick and well waiting rooms tell me that their receptionists spend at least part of each day helping parents decide which waiting room to sit in, moving patients from one waiting room to another, or settling angry squabbles between two families who are convinced the other’s child is in the “wrong” area.

Our receptionists would rather check in patients quickly – validating insurance information, updating phone numbers, and processing questionnaires — rather than serving as “waiting room police.”

There’s no evidence separate sick and well waiting rooms make a difference in controlling the spread of infection.

The American Academy of Pediatrics’ statement on controlling infection in pediatric offices states, “No studies document the need for, or benefit of, separate waiting areas for well and ill children.”

We believe that other commonsense precautions are more effective – like making masks, tissues, and hand sanitizer available in the waiting room; bringing children suspected of having an extremely contagious disease in through the back door; bringing extremely fragile/susceptible children back as soon as they enter the office.

When Should You Allow Your Child to Have A Cell Phone

This is a very common question from parents. I know my wife and I had to answer this question not too long ago.

Funny thing is, that our parents, and our parents, parents, didn’t have to answer this question. I find that fascinating. But our world is different now.In more ways than one.

Makes me wonder the type of questions they will have to ask themselves as parents 20 or 30 years from now. I can’t even imagine.

In this video, Dr. Wendy Sue Swanson from Seattle Mama Doc talks about when we should allow our children to have a cell phone.

Dr. Swanson practicing pediatrician and the mother of two young boys. She sees patients at The Everett Clinic in Mill Creek, Washington. She is also on the medical staff at Seattle Children’s and am a Clinical Instructor in the Department of Pediatrics at the University of Washington.

Dr. Swanson is passionate about improving the way media discusses pediatric health news and influences parents’ decisions when caring for their children. Dr. Swanson blogs regularly at Seattle Mama Doc

Quick Tips To Avoid Health Issues Associated With Winter

Written by Richard Lander, MD


Winter is here and as the song says, “baby it’s cold outside”. Here are a few quick tips to avoid some health issues commonly associated with winter.

First of all, make sure your children are dressed appropriately for the cold weather. That doesn’t just mean a warm coat or layering of clothes.

Since heat is lost from the top of our heads, have your child put on a hat on their head. Also, put a scarf or face mask and be sure to protect hands and fingers from getting wet and/or cold.

Gloves help protect the skin on  hands which tends to get dry.

When skin becomes too dry, your child’s hands may become cracked making the skin more susceptible to infection.

Be aware of frostbite. This is caused when the skin has become so cold that the circulation to the fingers is compromised.

The skin becomes pale or grayish in color and may blister. Next your child may lose feeling in her fingers. If your are worried that this has happened, place your child’s hands in warm water, about 104 degrees, which is average bath water.

Then carefully pat them dry and place them on dry warm cloths. If this happens to their nose, use warm, wet compresses initially,  but be careful not to rub and then use warm dry compresses.

Often playing outside in the cold weather leaves your child’s clothes wet. Take off the wet clothes as soon as they return inside, put on warm, dry clothes and drink warm liquids, such as soup, hot chocolate.

If you and your children are spending extended periods of time outside, remember to keep yourself hydrated; drink lots of fluids.

There are many outdoor activities to enjoy during the winter months, such as skiing, ice skating and sledding.

Make sure your equipment (skis, snowboards, blades on the ice skates or the runner of the sled) are in good condition and that your children have not outgrown them.

If they are taller this year you might need longer ski poles. Perhaps their feet have grown since last year and their ski boots or ice skates are too small.

Does their helmet still fit properly?

If the children are going to use a sled, make sure the the steering works and tell them to go down feet first, not head first.

Parents, when sending your children to the bus stop remember that it is dark and cold outside. Remind your children to stay on the sidewalk and look both ways before crossing the street.

A brightly colored scarf, hat or gloves is a great way to ensure that they are visible in the dark.

Winter is a fun time of the year. Be safe and be smart.

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

Parents, Are You An Active Participant When It Comes to Video Games And Your Children?

Post written by Dr. Natasha Burgert. Dr. Burgert is a pediatrician. She works at Pediatrics Associates in Kansas City, MO .  She is a distance runner and enjoys road races around the city. She also has a passion for travel that will certainly lead to many memorable family vacations with her husband and two children. And, of course, she bleeds Husker red. Dr. Burgert regularly blogs at

GamingI am a child of the Nintendo generation. I remember spending hours with that grey box, blowing on the game cartridge base to keep the game from being glitchy.

Personal gaming was fascinating, innovative, and exciting.  Our whole family loved it.  In fact, my brother spent so much time playing Super Mario Bros., he actually gave himself blisters on both thumbs.

Playing video games remains a hobby in our current home.  My husband and I own a gaming system, and a new video game is on my Christmas list this year.

My preschooler loves to play on the iPhone and iPad.  I am in no position to be doom and gloom for gamers.  I do, however, have parental control over our system, create limits for all members of our family, and engage cautiously.

There have been lots of studies about gaming and its effects.  What I find interesting is all the positive things about gaming.  Manipulating interactive media is going to be a critical skill for our kids to learn, and gaming is a fun way to practice.

Gaming is a wonderful social activity, allowing kids to engage in a form of fantasy play.  Developing relationships with peers of similar interest enhances self-esteem.

Studies have even suggested that individuals who are more inclined in gaming will be better surgeons due to improved hand eye coordination.

Games are being developed to help kids with medical conditions communicate and learn.  New Nintendo Wii games and XBox Kinect  are great examples of using gaming systems, or “exergaming,” for possibly productive weight loss.  And, games are fun!

So, why all the negative press about video games?

As game developers and creators know very well, games are additive.  Pediatricians are really concerned about the increasing numbers of overweight kids we are seeing in our clinics.

We know sedentary kids are at increased risk of developing obesity, and gaming is a sedentary activity. Excessive gaming may be associated with ADHD.  Certain types of games, such as first-person shooter games, have been associated with aggressive behavior and desensitization to violence.

Exposure to gaming may be associated with an increased risk of dangerous behaviors.

If your child wants a video games for the Holidays, here are some suggestions of how you can keep gaming a fun and safe activity in your home.

The AAP recommends no media (TV, computing, gaming) until after the age of 2

.Concerning studies have suggested that some families are allowing earlier media exposure.

I agree with the AAP that the formative years of development don’t need to be complicated with digital enhancement.

Learning to engage in independent play is such a critical, early skill that must be learned.  Developing this self-entertaining skill not possible if the majority of play is a passive activity consisting of watching pictures on the screen, regardless of the “educational content” of the program or game.

Early video systems do not help kids “learn” despite the marketing claims.

After the age of 2, what is appropriate for your family? 

There are many early gaming systems available including LeapFrog gaming systems, Nintendo DS, Sony PSP, computer and smartphone games.  These systems are getting increasingly advanced.

Browse the web to see the pros and cons of each gaming system.  In addition, see how much online support you are easily finding for each system. Included in many early gaming systems is an online partnership for additional activities.

For example, LeapFrog has coordinating non-gaming activities to do with your kids available on their website.

For more advanced systems, review the capabilities to determine what options you want available (web browsing, online gaming networks, exergaming, movie streaming, DVD/blu ray, music/photo storage, wifi capability.)

All major gaming companies have extensive websites to review.

When considering games to purchase, know what the game is about. 

Game content can be implied from advertisements about the game.  Most of the game ads can be easily found online, check or gaming blogs.  Do you think the content is appropriate for the members of your family?

Does the game have any components that may not coincide with your family values?  After purchasing a game, as soon as the game is opened, be ready to watch your child play the game. If you find some unexpected game situations you are not comfortable with, engage in conversationwith your child about those feelings.

Mind the game ratings, know what they mean. 

Every game is assigned a rating based on content.  Be sure that these ratings seem appropriate for the intended player.

A pre-teen/teen mind is physically unable to receive and process information like an adult.  Even though you think he is “old enough” to play a game like COD Black Ops, he or she may not be processing that input with appropriate filters.

In my opinion, “mature” or M-rated games are not appropriate for kids until late high school, if appropriate at all.

Consider what expectations you have for your family. 

What must be accomplished before play is allowed… homework? chores?  Explain to your kids that the gaming unit isyour property and may be removed from the home at any time.

If your child is unable to engage in other activities without the constant desire to get back home to game, recognize the red flag that is waving.  If you think your child is spending too much time, or too much engagement with the screen, create and enforce new boundaries.

Games are great for passing some time, but gaming should never be a replacement for interacting with your environment. I am surprised how often I am unable to have a conversation with a patient during a visit because they are allowed to stare at a personal gaming unit.

In our family, games are down when kids have the opportunity to improve and explore their social interactions with peers and adults.  That means we, as parents, need to be a model of this respectful behavior for our kids.

Set limits. 

The AAP recommends no more than 2 hours of screen time per day for our kids.  This includes all screens (TV, gaming, movies, internet, smartphones.)

I would argue that with all the media to which kids are currently exposed, limiting gaming to one hour per day is appropriate.

Gaming systems can provide very powerful motivation. Longer amounts of time can then be more effectively used as “special occasion” gaming or as a reward for responsible behavior.

Consider allowing play for the equal number of minutes engaged in active play (gym class, karate class, sports practice.) There are great tools to limit playtime, such as the BOB and the Time Machine.

Consider using these tools early in your child’s gaming experience.  Enforcing limits after your child is already overly involved in gaming is much more difficult.

If engaging in online play, be cautious. 

This is the area of gaming that starts to make me nervous for early gamers.  I am amazed how many families allow their young child to play online without supervision.

Some parents don’t even know their kids are even playing online! I get concerned when parents are not fully aware of the capabilities of the gaming unit in their home.

Online gaming is unregulated, the language can be vulgar and repulsive.  Online gaming is certainly part one part of the gaming experience kids love, and that parents need to be most aware.

One problem…where do most families have their system? In the basement!

Consider only allowing online play in a common area of the home.  Be present by frequently walking through the gaming area.

Headsets off for online play, you should be periodically listening to the conversations.

Know your network downloading capabilities, including pay upgrades, movies, and game update downloads.  Unregulated participation can end up with a pocketbook surprise.

Control your gaming unit. 

If you are allowing online play in your home, review the parental controls for your system. For example, XBox Live has an online family timer and security controls.

PS3 has an online “Playstation Knowledge  Center” to learn about unit settings.   Be aware that although you may have your privacy and security settings up to date, the person with whom your child has engaged play may not have similar values.

With very little effort, information on how to hack games, bypassing parental settings, is available through Google.  Bottom line… if you allow online gaming in your home, be aware.

That being said, keeping lines of communication open about gaming and the games your child likes to play is important.  You can only control what happens in your own home.  Exposure to gaming and an online community may happen when your child visits other homes.

Have fun shopping for these games. Watch their faces light up, then be an active participant.  If you need additional help, here is some information on choosing good video games.  There is also a book available about all things media which may give some good ideas.  Happy Holiday season, and happy gaming!!

P.S.  I do not have any vested interest nor endorse any products mentioned in this post.


What the NFL Referee Debacle Can Teach Us About the Future of Healthcare

Written by Brandon Betancourt

Even if you are not a football fan, I’m sure you’ve heard about the NFL and referee fiasco.

If you haven’t heard, here is the scoop. The NFL owners have been unable to reach an agreement with the referees. As a result, the referees were locked out and the NFL owners replaced them with cheaper less experienced referees.

The result?

Although qualified to referee a game, these less than professional referees don’t have the experience, the full requirements and the practice of a professional NFL referee. Consequently they’ve made some really, really bad calls.

Some calls have been so bad, that they have cost teams games.

In healthcare, there is a lot of talk about filling the primary care physician shortages that we expect in the near future, with mid-level providers such as nurse practitioners and physicians assistance.

Mid-level providers are competent healthcare providers. But they don’t train as long as a physicians do. As a result, they have less experience. On the flip side, they’re cheaper to train, and they earn less than a physician does.

Naturally, if you are trying to reduce healthcare cost, and you are planning on having a labor force shortage, mid-level providers seem like a good solution.

Don’t you think?

I think this is a bad idea. The NFL debacle is great example of what happens when one chooses to settle for next best.

For the record, I’m not putting down mid-level providers. I think they are valued team members. If I didn’t believe that, we would have not hired a mid-level provider in our practice.

I believe mid-levels have a place in our healthcare landscape and they will play an integral role in the future of primary care. But what I’m saying is, they are less experienced. They don’t go to school as long as a doctor does and don’t bare nearly the same responsibility as a doctors do.

Here is the thing, primary care doctors are tremendously valuable. Although they may appear to be expensive to visit, when you compare it to the value they return, the cost is minimal.

Think about it this way. How much would you pay to be assured that your child is healthy? What is the value of having a person that has dedicated 100% of their professional career to learn about children so that each child can reach their full potential?

Don’t make the same mistake the NFL owners did by choosing a less expensive, quick fix solution.

I can almost guarantee you won’t regret it.

Brandon Betancourt is a practice administrator. He blogs regularly at PediatricInc