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Personal View on Medical Care |
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 The photograph above was taken on June 15th 1866 by Charles Lutwidge Dodgson. You may know him by his pen name of Lewis Carroll as the author of Alice's Adventures in Wonderland. He did amazing things in his photographs of children. Although he may have had the two brothers above pose for the picture, that look is not something he could have requested. I like photos of children being real people with personalities no less formed than an adult's. I think that is, after all, the reality of childhood. The same things you might be frustrated about when you go to your own doctor are things I'm frustrated about when I go to mine. When I started my own practice, I wanted to try to improve some of these. The most important of these in pediatrics are access to your child's doctor, continuity of care with your child's doctor, and, most important of all, the time your doctor spends with your child and you. ?TIME Every parent knows how a 3-year-old reacts when even a beloved grandparent, who hasn't seen the child in months, comes for a visit and walks right up to the child and hugs and kisses her. It's not a pretty picture. It probably isn't rational to expect that same 3-year-old to be relaxed in a foreign environment with vague recollections of painful procedures while being approached unhesitantly by someone in a white coat who's trying to do incomprehensible things to her including, worst of all, look in her ears. All within 2 minutes of entering the room. Sometimes it's medically important to see if a child is unusually irritable or in pain. It could be hard to hear a heart murmur or a subtle change in breathing if the child is angry for other reasons. If the child is having a tantrum, she's not going to want to walk or talk on command, if that's what needs to be examined. I admit that I haven't seen any definitive medical study which shows that taking more time in a visit results in healthier children. But I wonder what the studies didn't measure. Things like being terrified of going to the doctor, perhaps for life. Maybe they won't want to take medicine that they really need. Maybe you're one of the parents who tell me (trying to seem like they're joking but not doing it very well) that they "hate going to the doctor." Why do they hate it? And why do they tell me? That leaves out how much more pleasant the whole process is if the kid likes the doctor. My professional expertise and experience has convinced me that true rapport with a child cannot be established without patience, gentleness, and time for children to get used to the new person and allow or even invite that new person into their space. I often wonder about pediatricians who don't seem to like kids. Go figure. ?TIME Here's the open secret about primary care medicine, for both children and adults. I think it's an open secret that you probably already know, but if you don't I'm opening it here. Primary Care practices get paid by the visit. So if the doctor sees 40 patients a day, and has scheduled visits from 9-12 and 2-4:30, that's 8 minutes a visit. And 15 seconds. Maybe you should have studied for that giant math test in school. That includes saying hello, writing prescriptions, writing a note about the visit, telling the medical assistant to do something or schedule another appointment. Because it slows the doctor down, it's just not a good idea to ask how school is going, to screen your adolescent for depression, to see if your seventh-grader has a clue what's going on with their body, to see if your second-grader is being bullied at school, to ask why the principal wants to hold back your kindergartener. It's certainly not enough time to talk about breastfeeding problems, behavior problems, the headaches or fatigue or bedwetting. In the kid, I mean. A lot of time, parents in these practices will bring up something really important just as the doctor is leaving the room, or even in the middle of an appointment made for another reason. Why do parents do that? Ironically, I think it's because visits are so short and because it's so hard to actually get some of the doctor's time and attention. If you don't think you're going to have another opportunity, you feel pressured to bring up everything at once. Many health-providing businesses are rewarding doctors for being more 'efficient.' The measure of efficiency used is how many patients they are seeing in a certain amount of time. They do this because it's easy to measure. Many of the things I value, maybe you too, are not easily measured. These include feeling like the doctor actually listened to me, that they really thought about what might be wrong and that they respected me enough to discuss the options with me. I also value the doctor examining me, or the relevant parts, anyway. Sometimes it's just a matter of talking to me and really getting all the details about my problem. I think this thoroughness is likely to lead to better medical management, and fewer untreated or poorly-treated health conditions. I also think it would relieve a lot of anxiety to know that someone whose expertise you trust is really thinking about what's going on with your child, even if they're open about not knowing for sure. The more experienced I get, the more easily I can identify many medical problems. But it's also clear that very few diseases have a specific test that shows if you either have the disease or you don't. Many illnesses have different symptoms or severity in different people. And very few medicines work just as well in everyone. ?CONTINUITY There's a lot going on in the course of a child's life, and doctors only get to see momentary snapshots, usually at random intervals when there's something specific that needs fixing. That's perfectly appropriate, of course. If your house had a sudden water leak, you'd call a plumber to fix it. [That might cost you more than going to the doctor.] But what if you needed new pipes throughout the house, to prevent something that might happen that was worse than a leak? What if a leak kept happening but every time you called, a different plumber came to fix it, and had to learn from scratch where the valves were in your house? I think you get the idea. Some things are pretty straightforward as far as medical treatment goes. But even these common problems can, in aggregate, present a new and different picture. The child who has a cough most likely has...a cough. Maybe it doesn't sound so bad, or had gone away, but then a few weeks later came back. And it keeps happening, mostly at night, for months. If the doctor seeing the child is meeting him for the first time, the doctor could listen to the child's breathing and accurately enough say that the child's lungs sound normal and recommend some cough medicine. But the pattern is one very suggestive of asthma, and a little asthma treatment might stop the cough altogether, as well as protect the child's health now and lung function later in life. I think if the doctor takes enougn time in the visit, and if the child sees the doctor repeatedly and likes the doctor, that makes the treatment and prevention of childhood illnesses and problems easier, safer, and much less traumatic. I like making kids laugh, and I'm getting reasonably good at it. This has taken a lot of serious work, as if iterating through a long Monte Carlo simulation of the permutations of interaction. Don't you regret not studying for that giant math test? Children have a gratifying intuitive grasp of game theory. Maybe--I'm just speculating here--it comes from playing actual,tangible, non-virtual, non-ersatz games. ?ACCESS In one practice I know, if you call after hours you get a recording that says if your child is sick, you should go to the local emergency room. They don't even offer the possibility of talking to a human. I like my doctor. When I'm acutely ill, I'm reassured by my ability, no doubt because of the privileges of being a fellow physician, to get an appointment with him in 3 or 4 weeks. Perhaps I should add a comment about hours of operation. In pediatrics, it's often best to see newborns in the morning. Usually one or both parents are not working those first weeks, so they can get there during the day. All the children in school or even preschool, however, might only get out at 3:00 or later. Even if they stayed home because of their illness, and hopefully they had an adult with them, there may not be anyone to take them to the doctor until a caregiver returns from work. And as every parent knows, babies always seem to get sick or have problems at night. Older kids usually get sick on weekends, during vacations, and on the day there's a giant math test. In general, I see doctors trying very hard to increase the distance between themselves and their patients. The way things seem to be at this time, it is accepted that your doctor is somebody who is available just by appointment in the office, and that patients, whether adult or child, are on their own otherwise. I remember when banks were open from 9:00am to 3:00pm, and there were no ATMs. We called them 'Banker's Hours.' It was a derisive term. It isn't reasonable to expect a doctor, or anybody else, to work 24 hours a day. But I think doctors have to be available. While my office has regular hours, of course, I always do my best to see you if you need to be seen. Even if it means early or late or even outside of the office somewhere. I imagined my practice in a house. I lived in the house and converted the garage into my office. I remember there were a couple of doctors like this near where I went to high school. I couldn't make this happen here because local zoning rules were very rigorous about medical offices. I don't know why this is. Maybe people don't like the idea of sick people next door, so they passed a law preventing it. But have you met your neighbors? Are they paragons of health? Go figure. *** This is Copyright 2006 and all rights are reserved. Nobody has permission to copy or publish any part of this on paper, on the internet or in any other way. The photograph image above was taken by me of a photograph I own and is on my wall. It is probably a really bad idea to take it and publish it elsewhere. |
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