5

Five Reasons Online Review Sites for Doctors Stink

Written by Suzanne Berman MD

The Internet provides plenty of opportunities for consumers to rate the quality of professional services they receive. A quick search can help you find recommended plumbers in your area, or suggest that you steer away from a certain roofing contractor.

Similarly, there are lots of online physician rating websites that offer the same service to consumers: check and see which doctors in your area are recommended by other patients.

I’ve watched the mushrooming of these “rate-the-doctor” websites with interest. While they provide an opportunity for patients to provide feedback to doctors and other patients, some elements could use improvement.

1 – They’re anonymous

Who is writing the reviews? While most come from true patients, there’s nothing to limit one single patient from sending 8 reviews about the same experience. For that matter, who’s to say good reviews aren’t from the doctor, trying to boost her image?

Physicians who are also small business owners (like me) from time to time terminate poor-performing employees. After a firing, does a spike in negative reviews of our practice reflect coincidence, or an ex-employee trying to retaliate anonymously– especially if the review contains “insider information” that our average patient wouldn’t be aware of?

2 – It’s not clear the patient is really a patient

When I read travel reviews online, I’m struck by how many reviews come from people who admit in their review that they didn’t actually stay at the hotel or eat at the restaurant. The review will read something like “I wanted to stay at this hotel because I’ve read so much about it, but when I clicked on the Reservations tab, I was shocked at the room rates. I couldn’t believe this hotel would charge so much for so little.

“They will never get my business!”

While the consumer is giving feedback to the hotel (“I think the market won’t sustain your prices”), this one-star comment hardly addresses what most travelers want feedback on (cleanliness of the rooms, friendliness of the staff, quality of the restaurant), since anyone can look up the prices for rooms.

Similarly, anonymous patient reviews don’t distinguish between a patient who came once, a long-term patient, and a prospective patient who has never been seen.

The latter’s comments are usually about a perceived access barrier to care, like: “I was new to town and needed a pediatrician. My son had terrible ear pain so I called to see if anyone could phone him in some antibiotics before the weekend. They were so rude and refused to help me out. I will never go there.”

Since I never had an opportunity to meet the family myself, never established a physician/patient relationship, and certainly never had an opportunity to explain, I don’t really consider this a review from a patient – but it’s in there with the rest of them.

3 – There’s no way to respond.

Some consumer rating websites, like Trip Advisor, allow the hotel or restaurant to respond or comment to a particular review. Many doctor rating websites don’t have a similar feature.

I don’t have an opportunity to apologize, or set the record straight, or offer to make my patient’s bad experience right. The patient can vent, surely, but I’d rather to try to reconcile the relationship.

4 – Patient privacy is protected.

Even if I can figure out who wrote a particular negative review, I can’t respond specifically in public with patient-specific information. Let’s say a mother posts a comment that I misdiagnosed her child’s ear infection: “even though Dr. Berman said Caleb’s ears looked great — later, when I took him to the ER, they said his ear was terrible.”

I review the child’s record: indeed, I examined the child in my office, who had clear ears. The child indeed went to the ER for worsening ear pain — five days later.

To me, this doesn’t speak to misdiagnosis as much as it does a common medical problem of kids: good ears sometimes go bad. I’d like to post something to clarify this online – to take the opportunity to educate families that ear exams can change over a period of days – but I can’t.

Simply, if I post any public health information about Caleb on the Internet, I’ve violated patient privacy laws (HIPAA). I can try to contact Caleb’s mother privately to make this same point, but she may or may not see fit to alter her online statement.

5 – Even the “neutral” information can be wrong.

“Rate-the-doctor” websites usually contain some basic demographic information, like the physician’s address, board certification status, age, gender, and so on. This information is often out-of-date, if not completely erroneous.

I’m amused to sometimes find that, according to some websites, I’m not board certified or that I practice at an address I haven’t worked at in seven years. Again, there’s often no mechanism for me, as the actual physician, to contact the site administrator to ask that my information be corrected.

So patients who come to these websites to get information about physicians may read bad information even before they look at the reviews.

Once it’s on the Internet, it’s there forever.

Our office periodically reviews our online reviews. A while ago we found one from a dissatisfied patient, rating us 2 stars out of 5, and concluding, “If there’s another place to take your kids, you should probably take them there, and not to this office.” The review was dated about 9 months prior to our discovering it.

The mother had left enough personally-identifiable information in the review for us to figure out who had posted it. Interestingly, in the 9 months since she felt dissatisfied with us, she was continuing to bring her son to us, and in fact had had a newborn daughter, whom she was bringing to our office for care.

We were puzzled that, if she were that displeased with our office, she hadn’t followed her own advice and transferred care to another practice. The next time she was in the office, we gently asked her about her review.

At first she looked blank; she’d completely forgotten she’d posted it! Finally she said, “Oh – that. Yes, I was dissatisfied with your office a couple of times, but since then I’ve kept coming, and now I’m much happier to be a patient here.”

We’re happy that she’s now more comfortable with us. Unfortunately, her review is still on the Internet, forever, and possibly no longer able to be amended.

Doctors are starting to fight back, and it’s not pretty.

While patients have the right to post opinions on the Internet, doctors who feel an opinion crosses the line have sued for defamation, slander and lost income. Doctors who respond in this way have drawn a lot of media attention – and many of them have a sudden increase in negative reviews posted.

This suggests that many of the newer respondents perhaps aren’t patients at all, but rather many readers are angry that a doctor would try to sue a patient for expressing her opinion. As far as a doctor trying to enhance her online reputation, it doesn’t seem to be a very effective method.

So what’s better?

Our office collects anonymous periodic surveys of our patients to learn how we’re doing and how we can improve. We ask patients to rate us on timeliness, friendliness, professionalism, and so on while they’re in the office as part of a visit.

This assures us that the reviews are being completed by actual patients, and that they’re being completed at the time of the visit, while impressions are still fresh.

Because we design the survey, we can make it specific as needed to help us identify problem areas: for example, rather than asking if “staff” are rude or friendly, we can ask for separate feedback on receptionists, nurses, doctors, billing staff, etc.

We’ve started sharing the results of our surveys with our patients, and we’re going to post future results on our practice website as well.

While our patients are free to comment about their experiences on rate-the-doctor websites, we believe posting results of our surveys will provide an equivalent service, and will be a more complete representation of our patients’ impressions of our practice.

Suzanne Berman is a practicing general pediatrician in rural Tennessee.

4

I’m Not Sure I Support Your Decision to Homeschool

Written by Suzanne Berman, MD, FAAP

My dear friends Matt and Jill are homeschooling their four children, and they’re doing an awesome job of it. Matt, no stranger to education (he has two master’s degrees) is a great communicator and very involved in his kids’ lives.

Jill is smart, sweet, and a model of organization; the “master whiteboard” in her kitchen reflects an orderliness worthy of a military quartermaster. Their kids are well-behaved, smart, curious, and articulate, just like their mom and dad. And the more time they spend with their parents, the more their parents’ character, values, and personality will be instilled in their kids. What’s not to like about homeschooling?

In the ‘80s and ‘90s, homeschooling pioneers fought for the right to direct their children’s educations. And they got good results, too. The original predictions of warped, antisocial children didn’t seem to pan out, and the early generations of homeschooled kids turned out as well-educated (if not better) than the average public schoolchild.

But I’m starting to see some disturbing trends in homeschooling: less Matt and Jill, and more child neglect and perjury.

Not too long ago, an 11-year-old boy came to my office for a well-child check, accompanied by his mom. “How’s school going?” I asked, as I a do always do. “Oh, I’m homeschooled,” he replied. “Tell me about that,” I continued, “what you like to learn about most?”

“Well,” he said, thoughtfully, “we usually do it on the computer. But we haven’t really done any school for a long time, so mostly I watch TV with my dad.” The boy and his two school-aged siblings had been pulled out of school one year prior because dad disagreed with the school’s assessment that the son was not performing at grade level.

The boy reported watching six hours of TV per day most days, with another two-to-three hours of computer game time per day. He might get in thirty minutes of the school program per day. Mom (and later Dad) separately reported that the boy’s self-assessment of school hours was correct.

“We’ve just been so busy with life,” they admitted, “we just haven’t gotten around to doing much school this year.” However, I didn’t see many hopeful indicators that things would change soon; mom works long hours at her job; dad is too disabled to work. When I checked in with them later, the boy couldn’t remember doing any appreciable school work in over six months.

Another mother came in with her 17-year-old daughter, 12 year old daughter, and 7 year old son. Mom reported that her three children are homeschooled; however, she is a single parent and is working 2 jobs to make ends meet.

Mother reports that her kids enjoy staying home. “We have it worked out,” mother explained, “so that while I’m at work, the oldest does her work on the computer. Then she can help the other two with their assignments.”

I gently asked the mother if being responsible for their schooling wasn’t overwhelming, given her work hours as a single parent. “No,” she said, “I don’t have to get them off on the school bus in the morning, so that saves me a lot of time.”

Similarly, a twelve-year-old told me this week that her “homeschooling” for the past three months has consisted of reading a novel — plus cleaning the house and keeping an eye on her fellow foster sibs so her foster parents can work. Other subjects? “No,” she said thoughtfully, “I really haven’t done any math or social studies or anything like that.”

Another mother came in with her twin 7-year-old daughters. The girls had matted hair and body odor. Mother, who had trouble keeping her eyes open during the visit, had lost custody of the twins when they were three years old for about a year; details were sketchy, but the Department of Children’s Services had been involved for a time.

“We’re doing great now, and I’m homeschooling them,” mother stated proudly, if sleepily. “They know all their shapes and letters, and we’re working on their colors and numbers.”

Families don’t have to be accountable to me for their school choice, but they need to be accountable to someone.

The homeschool umbrella (either a private school or local school district) at least nominally asks for attendance records and progress reports.

Even informal homeschool co-ops, which exist in many communities, help parents share best practices with each other. But the families that give me the most concern seem to have a lot of self-imposed isolation: the children don’t participate in music groups or sports teams, and the family doesn’t participate in community activities or attend worship services.

In extreme (and fortunately rare) cases, this can have heartbreaking consequences society expressed its disgust in the failure of child protective services workers to identify this perilous situation, but if someone from outside his family read Christian’s anguished “school essays,” might the outcome have been different?

There’s plenty not to like about public schools and private schools, and families in America certainly have the right to opt to home educate their children.

But public and private schools at least have requirements for transparency and accountability – in fact, that’s usually how we know which schools are winners and which aren’t.

Families like Matt and Jill, who still make up many of the homeschooling families I see professionally, occasionally express annoyance at required record keeping; they’re motivated to do it right even without oversight.

But when homeschooling families don’t appear to take their education responsibility seriously, and there are no consequences from their umbrella, who will hold them accountable?

Suzanne Berman is a practicing general pediatrician in rural Tennessee. Her study of Medicaid access was supported by a grant from the American Academy of Pediatrics’ Community Access to Child Health (CATCH) program.

2

To Teen Guys: Yes, We Really Need To Check ‘Em

Recently, I was called to our community hospital to consult on a teenager with severe lower abdominal pain. The young man, whom I’ll call Dan (not his real name), lived outside of our community, and I’d never met him before. I arrived in Dan’s hospital room, introduced myself, and started talking to him and his mom about his symptoms. After reviewing his chart and getting his history, I proceeded to examine his heart, lungs, and belly. Then I told him, “OK, I need to check your privates, to make sure everything looks healthy and normal. Is that OK?” I was unprepared for Dan’s surprised, negative, very forceful reaction: “NO WAY!” and his mother’s simultaneous exclamation, “No, you DON’T need to do that!”

I asked permission, as I always do, and he definitely hadn’t given it! So I backed up a little bit. “I know it’s embarrassing to have your privates checked. But we don’t have a good explanation yet for the pain you’re having, and if it’s related to something going on with your genitals or your bottom, I definitely don’t want to miss that.”

Dan was still pleasant, but I could see in his eyes he was definitely not buying my explanation. “If you would feel more comfortable with a man doctor, or without your mom in the room, we can definitely do that.” His horrified expression spoke volumes; I think he would have preferred a spinal tap without anesthetic.

His mom said, “Why do you have to do that? The emergency room doctor and the surgeon who’ve seen him today didn’t feel that was necessary.” I explained, in that case, if no one else had checked “down there,” I felt even worse about blowing off that part of the exam. Dan, still with the deer-in-the-headlights look, volunteered, “I had it checked at the clinic where I got my sports physical done. Can we count that?”

We talked about it some more, but Dan stood firmly to his position: “My genitals are not your business, doc!” In the end, I never did perform this important exam.

Clearly, I failed Communication 101 with Dan at explaining the importance of a complete body check, especially in a kid who’s sick enough to be in the hospital. I suspect if I’d known Dan better, he might not have felt so awkward. What I really wanted to communicate was this:

  • It needn’t take very long. A comprehensive external genital exam takes under a minute in boys.
  • We can do whatever it takes to satisfy modesty and cultural appropriateness. It’s OK to kick your mom out and have your dad come in. Or vice versa. It’s OK to request a male doctor. Or vice versa. It’s OK to have a chaperone — in fact, I prefer it that way.
  • We do find problems “down there.” Honestly, most doctors are in such a hurry – we wouldn’t waste time doing something if we never found a problem. In Dan, a rectal exam for his kind of pain would have helped reduce his need for expensive, high-radiation tests. From time to time, either as part of a problem check or as part of a checkup, we’ll find hernias, hormone problems, cancer, eczema, abnormal birthmarks, ulcers, urinary issues, and infections of many kinds (not just STDs). Many years ago, a wise pediatric infectious disease physician taught me to check the whole body – even the unmentionables – for clues to “mystery patients.” He was right, and since then I’ve diagnosed herpes encephalitis, Behcet’s disease, and Crohn’s disease – based primarily on what I found in the genitals and rectal area.
  • Parents, assume nothing. You may think your child has no concerns about his genitals because he’s never mentioned them to you. You may think your son could never have an STD. You may think your son would notice if he had a small amount of blood in his stool. You may think he knows what a hernia or testicular mass feels like. And all these things might be completely true. But they might not.
  • Getting it all “out in the open” makes it easier for a child to bring up a concern. Let’s say a young man discovers a small lump on his genitals, and it’s worrisome to him. When I’m doing a genital exam and already have things uncovered, it seems easier for a concerned teen to “casually” point to the spot and say, “Hey, [indicating] is this OK?” I can easily say, “Oh yes, that’s a ______ and lots of guys have those. They’re normal and won’t interfere with peeing or sex or anything. I have a great handout about that for more information.” It’s harder for a kid to bring up issues “down there” if he thinks that a genital exam isn’t part of the equation. Will I think he’s a pervert or weird for asking: “So… doc…. I have this… thing… on my… privates?”
  • Your female counterparts seem to have gotten over this. I’ve noticed (and I’m not sure why – maybe because I’m a woman) that I rarely have girls or their parents look horrified or surprised when I ask to check a girl’s breasts or pubic area. Much more frequently, I have mothers ask me, “Are you sure 13-year-old Kathy doesn’t need a complete pelvic exam, now that she’s having periods?” Sometimes this is a subtle hint to check for pregnancy or STDs; sometimes parents are trolling for information about their child’s sexual activity, or lack thereof. But much of the time, parents know that ensuring “the lady parts” are important to keep healthy, just like everything else.

So: It’s OK to be embarrassed. It’s OK to sigh, blush, groan, and/or roll your eyes at the doctor. But guys, yes, we really need to check ’em.

Suzanne Berman is a general pediatrician in rural Tennessee. She tries to minimize embarrassment to her husband and son, too.

Crossing State Lines: Crossing the Line?

In the search for reducing healthcare costs, some public policymakers have suggested allowing consumers to purchase health insurance across state lines. Theoretically, this would allow families to shop around for the best insurance deal, even if they aren’t a resident of the state in which the insurance is sold or regulated.

In general, increased access to choices drives down prices and increases competition; given the proliferation of online shopping for all kinds of other products, you might indeed find a great deal in another state. Even some state-based financial products, like 529 college savings plans, are marketed across state lines, allowing flexibility and consumer choice.

However, I’m opposed to selling health insurance plans across state lines: out-of-state insurance plans (including ERISA plans) can thumb their noses at a state’s consumer protection laws.

Here’s an example: Tennessee mandates that newborns be covered from the moment of birth to 30 days of age without any special action required on the part of the baby’s family (TCA 56-7-2301.) This is a good idea: moms shouldn’t have to call their insurance company’s 800 number in between contractions to ensure her baby gets added to her policy. The thirty-day rule gives families a short grace period to get their paperwork in order.

However, Tennessee law doesn’t apply to all infants born in Tennessee. Families who are employed by a big-box corporation headquartered in another state often have an insurance plan domiciled in that state. If mom and dad have, say, Blue Cross Blue Shield of Alabama — the company does not have to follow the 30-day rule of newborn care. They’re shocked to find out after their child is born (and too late to make other arrangements) that they owe hundreds or thousands of dollars to doctors and hospitals. It’s even more depressing when you realize these costs are incurred during a period when moms are taking time off work and family incomes are tight as a result.

Tennessee law also requires insurance companies to be transparent in their dealings with doctors: to pay clean claims promptly (56-32-126); to credential doctors fairly (56-7-1001), and to be up front about what doctors will be paid for their services ahead of time (56-7-1013). These laws protect employers, patients, and doctors from unfair insurance company tactics – but again, only as long as the company is an in-state company.

Our practice already spends a lot of resources policing our own state’s insurance companies. If they violate regulations, we can appeal to our state’s Department of Commerce and Insurance, our state’s legislature, and our state’s judiciary, all of whom are accountable to voters for their actions. Yet insurance companies in other states can blissfully ignore directives from our state, even though they’re insuring our state’s citizens. At last count, there were over 1300 out-of-state insurers during business in Tennessee; until consumer protections are more consistent, we need less of this, not more.

The Cost of Servicing Your Child

Written by Suzanne Berman MD

Several years ago, when I took my car in for servicing, I noticed this clever message printed on the back of the mechanic’s invoice:

This simple, honest explanation of my bill impressed me so much that I kept the invoice. More recently, I’ve thought about using a similar illustration for patients who ask, “I don’t understand why my pediatrician’s bill is so high – I only saw the doctor for about 10 minutes!”

Using the auto mechanic’s model, I’ve taken our practice’s actual expenses for 2010 and broken them down by category, as well as percent of our total budget, to give you an idea of where the money goes.

So with apologies to the creator of the automobile piece, here’s what goes into the cost of servicing your child:

Utilities and rent: 10% We spend a tenth of our budget just keeping the lights on, the telephone ringing, the heat and A/C running, and the rent paid.
Supplies: 9% Nearly another tenth of our expenses go to supplies, both clerical (appointment cards, copy paper, and pens) and medical (gauze pads, diapers, and casting supplies.) The largest single supply expense we have is vaccines; it’s not uncommon for a busy pediatric practice to have many thousands of dollars in vaccine inventory at a time.
Clinical staff: 13% Our nurses and medical assistants are busy from open to close – they weigh and measure our patients, draw blood, give shots, answer medical questions, complete school and camp forms, return phone calls, coordinate referrals, talk to the home health agency, refill prescriptions with the pharmacy. All these astute individuals are friendly and talented; we want to keep them, so we try to pay them well.
Receptionists: 5% Our front office staff answer the phone, verify insurance, check in patients, distribute paperwork, send and receive medical records, mail and fax documents, process co-payments, confirm appointments, order supplies, and more.
Insurance jockeys: 4% We don’t have “car jockeys,” but we do employ three full-time staff who could be described as “insurance jockeys.” These longsuffering individuals send claims to insurance companies (a big task) and argue with insurance companies when payments aren’t made properly (an enormous task, as it’s estimated that 20% of insurance payments are wrong.) They try to keep up with policy changes in the 200+ insurance plans our office sees in a year. They also work with families who need to establish payment plans, need to get insurance, or who are having trouble navigating their insurance plan.
Supervisory staff: 8% All our other staff have to be trained and supervised. Someone has to approve their mileage forms, overtime requests, time clock totals, and benefits changes. Someone has to negotiate scheduling squabbles, process payroll, conduct staff meetings, plan the office’s Christmas party, write policies (then rewrite them when they’re unclear), meet with vendors, fix the computers when they’re acting up, call a plumber when a toddler accidentally flushes a toy down the toilet, and about 384 other major and minor things to keep our office running. These staff also have associated professional costs, like dues and subscriptions.
Building maintenance: 4% Keeping our office clean and well-maintained is hard work for the husband-and-wife team who spend several hours 5 evenings a week cleaning, disinfecting, dusting, vacuuming, waxing, touching up the paint, wiping fingerprints from walls, emptying the trash, getting bugs out of the light fixtures, and more. Seasonally, we also pay a landscaping service (to maintain our grass and plantings) and a guy with a big truck (to salt and de-ice our parking lot). This also includes budgeting for major repairs, like resealing and restriping our parking lot every couple of years, fixing leaks in the ceiling, and cleaning up fallen debris after a bad storm.
Specialized physician training: 22%. This represents the salaries for the pediatricians in our practice and, yes, paying the doctor is the largest single expense in a practice. Much of this goes to the doctor’s personal overhead: Physicians now graduate med school with an average of $150,000 in educational debt.
Capital investment: 6% We use electronic medical records at our office, so all of our staff have their own computers, and there are computers in each of our exam rooms. Computers have to be replaced every few years, as do other electronics, furniture, appliances, and tools.
Taxes: 6% The largest part is payroll taxes for our employees and self-employment taxes for our physicians – but also unemployment tax (federal and state), property tax, professional privilege (license) tax, and sales tax.
Insurance: 7% We pay malpractice insurance for our professional employees, of course, but also insurance on our building and equipment, health/dental/life/disability for our employees, worker’s comp insurance, and some other odds-and-ends premiums.
Fringe pay: 5% This includes vacation/sick pay, holiday pay, and our company’s contributions to our staff retirement plan.
Wage and hour regulations: 1% Overtime wages for our employee constitute nearly 1% of our total annual expenses.

 

When you pay your pediatrician’s bill, your pediatrician certainly takes home a portion of that, but most of it goes to other things to keep the office ready and running. While our practice isn’t necessarily representative of all pediatric practices – and I know from published benchmarks that our practice is atypical in at least a few ways — this hopefully gives a rough idea of where the pediatric healthcare dollar goes.

Suzanne Berman is a practicing general pediatrician in rural Tennessee.

2

Mr. Obama Has Some Reading to Do

By Suzanne Berman, MD

The Obama administration recently announced plans to use a series of “mystery shoppers” to see whether it’s true that patients with Medicaid have problems getting appointments with doctors.

This isn’t just idle curiosity; Medicaid patients are supposed to get care equal to privately-insured individuals. The equal access provision of the Medicaid Act, 42 U.S.C. § 1396a(a)(30)(A), states that:

“A state plan for medical assistance must . . . provide such methods and procedures relating to the utilization of and the payment for, care and services available under the plan to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population.”

While I’m pleased to see that someone at the federal level appears to be paying attention to Medicaid access problems, this initiative wasn’t all that novel, and in fact seems downright redundant: for years, doctors have been documenting the difficulties with Medicaid access in peer-reviewed medical journals.

About ten years ago, pediatrician and AAP president Steve Berman published a study that documented that, nationally, children with Medicaid indeed had much poorer access to private pediatricians than their privately-insured counterparts. Based an excellent cross-sectional survey of private pediatricians nationwide, its results were impressive for their comprehensiveness; the conclusion wasn’t that surprising or novel, even in 2002.

Since then, the Medicaid/private insurance access to appointments disparity has been studied broadly, again and again – with strikingly similar results every time. Just a few of the studies conducted within the past decade (many of which have even used the “mystery shopper” technique) include evaluation of:

Even yours truly at Survivor: Pediatrics compiled a survey of Tennessee pediatricians showing that Medicaid-insured children in Tennessee do not have the access to pediatricians enjoyed by their privately-insured counterparts.

A few days after its announcement, the Obama administration announced that it was cancelling its mystery shopper initiative. Hopefully, someone decided that re-inventing the wheel wasn’t necessary after all.

Suzanne Berman is a practicing general pediatrician in rural Tennessee. Her study of Medicaid access was supported by a grant from the American Academy of Pediatrics’ Community Access to Child Health (CATCH) program.

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.

2

Schoolteachers Are Awesome – School Health Policies, Less So

Schoolteachers are awesome.

They exhibit saintlike patience and calm with tantrums, vomit, and playground injuries. They watch child development in real-time and understand intuitively that what is normal for one child might not be normal for another. And they genuinely love children, which makes them good parent material. It’s probably not surprising that schoolteacher moms and dads top the lists of my favorite families in our practice.

I also have a lot of respect for schoolteachers because they seem to deal with many of the same frustrations that pediatricians struggle with. Teachers, like pediatricians, find that parents can be a child’s biggest advocate in life, but also parents can be a child’s biggest barrier to success. Teachers also seem perpetually consumed with meetings, regulations, and paperwork, with less and less time given to one-on-one classroom care each year. Teachers also suffer the consequences of unfunded mandates.

It seems a no-brainer that pediatricians and teachers ought to be allies for children’s well being.

So why do pediatricians seem to be at odds with the school system so much of the time?

My colleague Dr. Fierstein posted recently on Survivor Pediatrics the absurdity of needing a doctor’s note to apply sunscreen in New York schools. Her plaintive appeal to common sense seems a no-brainer and started me thinking about other ways that our public school systems suck health care dollars.

The cost of school notes.

In most school systems, children are allowed a certain number of “mommy excuses” per semester or year. However, children who exceed this threshold must have their absences excused by a doctor’s note; parents without doctors’ notes face truancy charges. Consequently, parents want to collect a doctor’s note each time their child is sick so they can save their few “Get Out of School Free” cards for emergencies.

Some doctors are OK with issuing these notes by telephone. Certainly, there is still a cost to this; someone has to answer the phone, get the information, and fax a note to the school. As I’ve said before,  I’m hesitant to certify over the phone an illness that I haven’t personally evaluated.

In this case, my main reason for refusing to do doctor notes over the phone is that it adds nothing. If a mother calls the school and says her child is sick, the school won’t accept it. But if a mother calls me and says her child is sick, and I write a note to the school saying “Mom says her child is sick,” that somehow becomes acceptable documentation for the school.

The school expects me to take mom’s word for it but is unwilling to do so itself more than five times per semester.

This neatly passes the buck (or should I say, the bucks) to me, the de facto attendance secretary. And an MD is a pretty expensive attendance secretary. So our policy is: if you’re sick enough to miss school and need my note, you’re sick enough to come in.

In these cases, parents know their children have colds, stomach viruses, and other mild self-limited illnesses which require kids to miss a day or two of school. There’s no diagnostic dilemma, no prescription needed, no particular question that needs my expert opinion. Nonetheless, I estimate that at least 15% of school-aged children coming to my office for a sick complaint are doing so simply to get a school note.

Direct medical costs of getting school notes

What does it cost the health care system to provide these kinds of notes for a school system? Here’s a very rough estimate.

· Number of sick visits to our pediatric practice of school-age kids between August 2009 and May 2010: 5700

· Percent of visits just for school notes: 15% (low estimate)

· Cost per sick visit of this type: $50 (low estimate)

· Total annual cost: $42,750+ just for patients of our practice.

This would more than cover the salary and benefits of a full-time county schools employee, who could monitor attendance and follow up by telephone or home visits to frequent absentees.

If our practice is representative, Tennesseans are spending at least $14 million per year in private and Medicaid health dollars to fund school notes. (This doesn’t, of course, account for the indirect costs to parents, such as transportation to and from my office.)

I suspect that if school systems needed to foot the bill for these office visits, they would quickly find more cost-effective ways to monitor attendance. And I’m not sure we pediatricians have done enough to discourage these kinds of school policies; as you can see, this fairly reliable revenue stream might present a conflict of interest. But it’s not a good use of limited health care dollars. Let’s save the doctor-issued school notes for when there’s really a question for the doctor – like, “Is Kaitlyn’s rash contagious, or can she go back to school?” or “When can Chad return to football after his concussion?” Something may be able to subsidize a cash-strapped educational system, but it shouldn’t be the health care system.

Suzanne Berman is a general pediatrician in Tennessee. Both she and her son, Simon, think that his third grade teacher, Mrs. Hutchings, is really awesome.

21

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.

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.