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

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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.

However…

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.

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How Well Visits Are Billed and What Happens if a Problem is Found?

Written by David Sprayberry MD

In a previous post, I tackled the subject of what constitutes a well visit. Today I will try to explain the way well visits are billed and what happens if a problem is found and/or addressed at the same visit.

Medical billing is quite complex and is based on a process called coding. I will see if I can explain it in a way that makes sense. Let me know if I was successful.

Think of your medical bill for an office visit as being similar to the bill you receive at a restaurant. Each service, procedure, lab, and screen is billed separately just like each menu item is billed separately at a restaurant.

When you go to your doctor for a visit, he or she is required to follow certain rules, called CPT and ICD-9 rules, for describing what happened during the visit (unless he does not accept any insurance and is paid directly by the patient for the visit).

Each thing that is done during the visit has a code and each diagnosis has a code.

The physician must report these codes to the insurance company in order to get paid for the work that was done. There are codes for well visits, codes for sick or problem visits, codes for each test, codes for each vaccine, and codes for each procedure.

If these codes are not reported correctly, your doctor will not be paid for the visit.

Many times they are reported correctly and your doctor still does not get paid correctly by the insurance company (which is generally due to a “mistake” by the insurance company).

Most medical offices have one or more employees whose entire job is to report these codes and to make sure the insurance company or patient actually pays correctly for them.

At a well visit, the typical codes that are reported to the insurance company are the well visit code, codes for each vaccine, codes for the administration of each vaccine, and codes for each test or procedure (like hearing, vision, hemoglobin, lead testing, developmental screening).

These codes are all linked to the diagnosis “well child”. Depending on the insurance plan, some or all of these codes are “covered services” and are paid by the insurance company.

Sometimes the insurance company requires the patient/parent to pay for all or part of a visit (either in the form of a co-pay, deductible, or because the insurance company doesn’t cover a particular service).

This depends completely on the contract between the patient/parent and the insurance company. The physician’s office is required to collect from the patient/parent whatever the insurance company didn’t pay.

What often causes confusion is when there is an illness or other problem that is addressed or treated at the same visit.

For example, if I were to find an ear infection and treat it, I would be required to submit a code that told the insurance company I had taken care of a problem and done more than just the well visit. This is where the confusion for parents may start and here’s why:

Many, if not most, insurance plans require the patient to pay for a portion of any services that are not part of the well visit. Depending on the plan, the patient may need to pay a co-pay or may pay the entire amount of the extra service if they have not met their deductible.

Whether they need to pay this is determined by their insurance company, not their physician. The insurance companies have intentionally designed this system to create tension between the patient and physician, when, in reality, the insurance company has caused the need for the parent to pay the extra amount.

The physician merely did her job and described the visit accurately to the insurance company.

To summarize, the physician reports the codes that describe what occurred at the visit to the insurance company. The insurance company reviews the codes and determines if the patient owes any additional fee to the physician.

Whether the patient owes anything depends entirely on the patient’s contract with the insurance company, not by the physician.

I hope this helps clarify the issue. Please feel free to share your comments or questions.

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.

Photo Credit – Dr. Nan

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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.

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Dr. Google, Friend or Foe?

Written by Natasha Burgert MD

Two articles recently caught my eye while I was spending some time on Twitter. First, an op-ed piece was published on Time.com discussing how patients and doctors perceive the use of the online health information. The article was closely followed by the results of a recent PEW research study which stated that 80% of Americans used the internet to “prepare for or recover from” their doctor visit.

The results of the PEW study were less than surprising to me. Everyday I have a concerned mom or anxious dad refer to something they have read online.

Everyday.

And, everyday I get to learn about new articles and websites that are claiming to have reputable health information. I learn from my families who bring in articles and links, and often share the good information with other families who may be struggling with the same concerns.

As a medical doctor who regularly navigates the web, however, I did not expect nor appreciate the author’s tone in the Time.com piece. I was made to feel that all doctors were like lazy cattle, being poked with an electric switch towards a glowing computer screen.

I find that troubling as a practicing pediatrician. Although doctors have traditionally been thought of as “late-adopters,” not all of us fit that archaic mold. There are many, many doctors who are embracing e-communication of all types within their daily medical practice. And all successful doctors practice “shared clinical decision-making” with their families, regardless if the internet is a piece of the information puzzle.

How can you discuss online health information with your physician, without being labeled a “cyberchondriac?”

Here are some things to consider before you approach your provider with some internet research of your own.

Critique what you find

Commercial advertisers and agenda-based groups can be very deceiving online. Does the information have sources to original, peer-reviewed medical articles?

Who is writing the article, and what are their credentials? Who is paying for the study to be completed? Are there a lot of banner ads, or references to a certain brand of product? Does the writer of the article have financial interest in the items they recommend? Dr. Meisel did state this well, saying,

Many patients are going to discover the best online health information way before their doctors do. They, too, have a responsibility: patients will need to signal to their doctor how they conducted their search in a way that was smart, directed and grounded in evidence. Only then will the Google stack be recognized and used in a helpful, not counterproductive, fashion.

My favorite public sites for health information include:

  • Is your child sick? This feature is on our practice’s website to give families some information about common childhood symptoms. The site also give some guidance about what symptoms are concerning enough to contact the on-call physician.
  • www.uptodate.com This is a very well-designed site providing general information on health conditions and their treatments.
  • www.healthychildren.org A website full of childhood health information developed by the American Academy of Pediatrics.
  • www.cdc.gov General information on illness, vaccines, and travel concerns.
  • www.vaccine.chop.edu Complete, concise vaccine information.

If your provider allows, send links and articles to your doctor before the visit

Bring a list of keywords that you searched. This allows your doctor to look over the information more critically, and hopefully more thoughtfully. If your doctor does not allow you to provide information prior to your appointment, don’t expect organized discussion about your findings in a brief appointment slot. Thinking about online information critically is a time-consuming process. Give your provider ample time to look over the information after your appointment.

Be prepared for a “no”

It may be possible, that despite your best efforts, keywords or articles you have found may have been misleading. If your physician disagrees with some online information you have found, it is very appropriate to ask, “Why?” Your provider should explain why the information may not be relevant or appropriate for your specific situation, hopefully providing alternate online references to help continue your search.

We are partners

Bring information to your provider with an attitude of partnership and shared decision-making. No one likes a confrontation. Navigating health online information is a learning process for all of us. If we don’t listen to each other, we don’t learn.

If patients and doctors can have open dialog about information found online – good and bad – we can take care of patients better. And that is more than Dr. Google could ever do alone.

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 kckidsdoc.com

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Paying for your restaurant bill and your doctor’s bill is not that different

Written by Brandon Betancourt

I got a call from a mom recently. She wanted to know why she was being charged for both a preventive wellness visit and an office visit on the same date of service.

For those that don’t know, most visits to a pediatrician’s office are either considered an office visit, which generally include visits where the patient is sick, and wellness visits – which are those visits where the doc does a more comprehensive head to toe assessment of the child otherwise know as a physical.

This particular patient came in for a wellness visit, but the doctor also documented and addressed a heart condition that the patient has. The heart condition assessment triggered an office visit in addition to a yearly physical. In other words, our office submitted a claim to the patient’s insurance stating that both an office visit and a physical occurred during the encounter.

Mom wanted to know why the two charges since she was under the impression that checking a patient’s heart should be part of the physical.

I understood where the mom was coming from. Medical billing is very complicated and in many instances doesn’t make any sense. Not because the doctor or her office makes it complicated, but because the insurance companies designed it that way.

Here is how I explained it to her.

When you go to a restaurant, and order a dish, generally the meal will come with side foods. So, let’s say one is ordering a pasta primavera. The expectation is that in addition to the pasta, the dish is going to come with vegetables, which are included in the price of the dish.

Let’s say one decides to add chicken to the pasta primavera and the server says, “sure, but that will be extra.”  Meaning, she will have to charge extra for the added chicken. When asked what you’ll like to drink, 9 out of 10 times, beverages will also be extra. And so will appetizers.

Healthcare is like an a la carte restaurant where some things are included in the price of the visit, but others are not.

But here is where it get a little complicated. Unlike the the restaurant, patients don’t pay for their bills directly to the doctor; insurance companies pay the doctor. And insurance companies, in an effort to provide more shareholder value, prefer to pay for the least amount of claims possible because the less they have to pay, the more money they make.

Thus, they require physicians to document everything that happened during the visit so they can determine how much they have to pay based on the policy purchased by the patient. In other words, they won’t take the doctor’s word for it. They want to see and review everything that was discussed during the visit  with the patient so they can decide what should and should not get paid.

During this particular patient visit, I explained to the parent, in addition to the wellness visit, the doctor also assessed the child’s medical condition, which required the doctor to prescribe medication, order x-rays and a consult with a specialist.

Just like the appetizers and the added chicken is billed as “extra” at a restaurant, the assessment on the child’s condition was extra work for the doctor that is not included with the wellness visit payment.

And in her documentation, the doctor described to the the insurance company that the patient had required an “appetizer” and “chicken,” thus they should pay her more.

Essentially, the doctor was simply documenting the visit with everything she did in order to demonstrate to the insurance company what was done. And the heart condition assessment documented by the doctor triggered an office visit.

The parent appreciated the analogy and said that it was perfectly reasonable explanation. I was happy. I was able to communicate without insurance jargon and was understood. In my world, this is considered a good day.

Brandon is a practice administrator, speaker and blogger. He blogs regularly at PediatricInc.com

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A Day in the Life of a Pediatrician

Written by David Spraberry MD

Ever wonder what your pediatrician does all day? Ever wonder why you sometimes have to wait to be seen (or, in my case, many times)? Doesn’t he or she just spend 8 hours a day at the office and then go home? Why does he sometimes seem a little tired? How can she be tired if she only works 4 days a week in the office?

If you have ever wondered about those things, I am going to give you a peek into what my typical work day looks like.

6:00 a.m. – Get up and get ready for the day. (If I am really disciplined, I will get up at 5:00 or 5:30 so I can exercise.)

6:45 – Leave for the hospital

7:05 – Arrive at first hospital, make rounds in newborn nursery, then move on to the pediatric ward to round on inpatients.

8:00 – Leave first hospital and go to second hospital. Repeat the above.

8:45 – Leave second hospital and drive to office.

Note: I do not always have patients at both nurseries and both pediatric wards. I do often have to go to both hospitals, though. If I don’t have patients at both hospitals, I go get some coffee and spend some quiet time before the office.

9:00 – Arrive at the office to start the office day. I am usually met with multiple questions that relate to patients who might need to come in immediately but don’t want to, or who must have this form now or they won’t be able to go to football practice (but they didn’t bring it in until this morning), or I find out that a staff member won’t be at work today because they are sick or something urgent happened. Or, if it is winter, “The schedule is full already, where do you want to add sick patients?”.

9:05 – Start seeing morning patients. I will generally see an average of 4 patients per hour. In winter I may see 6 per hour. In summer, I may see 3 per hour, depending on the type of visits. Between patients, I am usually greeted with more questions about where to fit someone in, presented with more forms to sign, forced to be cordial to the drug rep who is bringing in the samples that we need and has her boss with her, have to call back to the hospital about a patient, or have to argue with an insurance company about approving the MRI that our patient desperately needs to prove she does not have a brain tumor or spinal injury.

Along the way, I do have the great privilege of conversing and playing with lots of fun little kids while making the best medical decisions for them that I am able. The relationship with the kids and their parents is what makes all the other hassles worthwhile.

1:30 – I finish my “morning” after 6 1/2 hours of work. I then move on to my lunch “hour”, which is usually less than 30 minutes and is spent reviewing labs, returning phone calls, and signing forms while shoveling in whatever I happen to have available for lunch that day.

2:00 – I start the afternoon and do more of what I did from 9:00-1:30. The after school phone calls begin and we work to try to fit in those kids who got picked up from school sick. If our schedule for the afternoon is already full, we usually add those kids on anyway and stay late to see them, unless I have a firm evening commitment that requires me to leave by a certain time. Right before closing is when the asthmatic in severe respiratory distress walks in and must be urgently treated in the office while arranging for admission to the pediatric ward.

5:00-7:00 – I will finish seeing patients somewhere between 5:00 and 7:00, depending on the time of year and day of the week. Once all patients have left the office, I will usually still be at the office for another hour or two finishing documentation and making phone calls. If I admitted someone, I will also dictate the admission note and follow up on any admission orders that I have done.

6:00-8:30 – I finally make it home somewhere between these hours, depending on time of year. My family has usually eaten dinner already, so I will either eat quickly and start hanging out with the kids, or I will hang out with the kids and then eat dinner once they have gone to bed.

9:00-11:00 or 12:00 – The kids have made it to bed and I can then start handling the personal responsibilities that I have that are not directly related to seeing patients, like paying bills, catching up on medical reading, working on “maintenance” of my board certification, and, oh yeah, actually having a conversation with my wife.

11:00 or 12:00 – Finally I go to bed so I can repeat the above tomorrow. I will probably get about 6 hours of sleep, though I need about 8.

Not every day is this way, but many are. Once the kids are in bed, I may do some kind of leisure activity instead of the work-related things mentioned above, but this is a fairly decent representation of my average day.

Since my partner joined the practice last year, I do have more time for leisure activities since she splits the hospital duties and phone calls with me. My days and weekends off are usually spent hanging out with the kids and taking care of office planning activities that I can usually not accomplish if I am scheduled to see patients.

So there you have it. A typical pediatric work day for me. Some pediatricians will work longer hours than I work. Some will work fewer days and fewer hours than I do. Most will have a similar set of responsibilities that they must somehow manage while seeing patients in the office, making the right medical decisions, and not getting too far behind schedule.

Despite how hectic things can sometimes be, I am glad to be a pediatrician and I don’t know what else I would do with my life. The whole professional athlete plan just didn’t pan out, although some of those NFL kickers manage to keep kicking until they are 50…

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.

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How Pediatricians Can Help Through Your Adolescent’s Transition

Written by Jesse Hackell MD.

In pediatrics, perhaps uniquely among the fields of medicine, change is more than something which just happens. It is at the very core of growth and development.

There is no stage of life which manifests growth and development more than childhood. For pediatricians, change is a part of every visit (“her development and growth have been right on track since your last visit”) and part of every piece of guidance and advice that is given to parents.

In fact, “anticipatory guidance” is specified as a standard element of preventive care visits, at every age through the pediatric and adolescent years. We comment on how a child has changed since the last visit, and suggest the changes to be anticipated during the months before the next one.

A child who does not change from day to day, month to month, is so unusual as to be cause for concern.

I have watched the transitions of my now-adult son and daughter, living through every stage of their growth and development, from infancy and toddlerhood, through the early years of school, sports, friendships, puberty, right on through college and graduate school, into adulthood, marriage and, soon, parenthood. Living with this change on a daily basis, one can almost forget the magnitude of the changes they go through, as they seem mostly the same day to day, until, suddenly, they have woken up one morning as a totally new person.

But in practice, we see children episodically—frequently in the early years, but less so as they grow, so from one visit to the next, the changes are notable and dramatic.

I was particularly struck by this recently, when on one busy Monday, of the 12 well visits I had that day, nine were for long-time patients getting ready to start their freshman year of college.

Many of these young people had been my patients since birth—one mother reminded me that I had attended the delivery of the young woman I was about to examine, and thus had really been the “very first person to see her.” While others had become patients at somewhat later ages, none were strangers—all had been coming to our practice at least since before they entered the teen years.

I had seen them over the years for visits both well and sick; had treated their acute illnesses; had counseled them on exercise and health, safety and risk behavior; and had gotten to know them and their families, and watched the changes that are common to us all as they occurred in each of them.

The pre-college physical is a different sort of visit. Many of the kids, as I still call them, come on their own, without a parent.

But it is most different in my view for what it represents in terms of the adolescent’s burgeoning independence.

While they may have varying degrees of independence while in high school, and living at home, for those who choose to live away at college, this is often the first prolonged period of time living away from their parents, as well as the first episode of living in a peer group, and having to learn the new social skills necessary to get along, fit in and succeed in that new environment.

While most of these 18 year olds are excited about the prospects of college, it is fair to say that most are also having some trepidation about it as well. It is always a part of the visit for me to mention this ambivalence that many fear, and to let them know that it is normal and expected, as well as that it usually eases quickly upon meeting new people who are also going through the same experience.

It is also important to acknowledge the transition that occurs when young people start living independently in terms of needing to develop the skills of self-monitoring and self-control, in the absence of supervising parents.

Many will need to assume primary responsibility for managing chronic health conditions, from diabetes to asthma to ADHD, and part of this pre-college visit is concerned with making sure that they are current with their management, as well as knowing how to get help if things do not remain stable once they are away from home.

Alcohol, drugs and other risky behaviors are an inescapable part of college age, and it never hurts to remind the newly independent that they, alone, will be responsible for the choices that they make, in terms of both health-related behaviors as well as academic behaviors such as classwork and studying.

One aspect I emphasize is the benefits of having a medical home.

We have been their trusted source of care for many years, and I emphasize that we are happy to continue to provide that care for them until they graduate from college (always emphasizing that I mean on the “four-year plan.”)

For practical reasons, since many are only at home sporadically over the course of a year, it makes little sense to try to establish a relationship with a new physician in bits and pieces.

Additionally, we know their medical history, and we make it a point to see them (as we do for any of our patients) on an immediate or same-day basis for their acute problems, which is important when they may only be in town for a long weekend and cannot wait three days for the next available appointment.

It always amazes, and gratifies, me how many respond to my offer to continue to be their physician with a comment such as “I don’t ever want to go to another doctor, even after I graduate.” It just demonstrates, once again, that transitions, although ongoing and inevitable, are fluid and variable in their nature.

That is part of the beauty of change—it is going to occur, but we can all do things to help make it smoother and easier. It is what you make of it.

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.