Wishing You Merry Christmas Card
Find unique and modern Christmas cards at Shutterfly.
View the entire collection of cards.
Saturday, December 3, 2011
Saturday, September 17, 2011
Are Your Child's Behaviors or Emotional Reactions of Concern?
Keep in mind that I am a general pediatrician and a mother, not a psychiatrist or psychologist. I received the education a board-certified pediatrician is exposed to during her training and ongoing maintenance of certification. My experience has developed over the years, as I have interacted and provided health care for many children. I have a few validated assessment tools I can use when I need a more objective point of view. However, to get an idea of what is going on, mostly I talk to parents and children and observe children in my office.
Now, having properly oriented you, I want to let you in on some of the big things I consider when trying to help parents figure out if their child has a behavioral or emotional problem beyond the range of normal variation or development.
1. HAPPY?
I want children generally to be happy and able to participate in school and the activities they usually want to do. Certainly a child will have ups and downs, good days and bad, temper tantrums, mood swings, and upsetting things that happen to them. However, overall, a child will normally stay interested and have some enthusiasm for family, activities, friends, and at least some parts of the school day.
2. PARTICIPATING IN LIFE?
I don't want a child's behaviors or emotional reactions over time to significantly limit their participation in family life, the school setting, friendships, and individual interests. Again, this doesn't just mean having a bad day, or week. The overall arc of a child's day-to-day life should allow them have the experiences they need to develop meaningful relationships, independence, confidence, and self-esteem.
3. FITTING INTO THE FAMILY?
We have to get to know our children. Different temperaments respond better to various forms of discipline and structure. A frown and slight shake of the head may bring one three-year-old to the point of tears, while another won't respond until they have had several time-outs and a toy taken away! Still, unless it is necessary because of a child's young age or special needs, a family should not have to adjust everything they do around a child's behavior or emotional reactions. If, because of their child, parents find themselves usually quite limited in the places they can go, food they can eat, and people they can visit, this might be a concern. Or, if a time-consuming amount of planning is necessary to get out the door, get a child to school, stay on a schedule, make sure the right snack and drink is available, etc. then this could be a red flag.
Can I generalize and say that if a child is usually happy, participates willingly in life, and fits into the family then there is nothing to worry about? Probably it's not that easy! However, if one or more of the above three questions starts to reveal a persistent problem, then I know I will have to look into it further.
Your personal pediatrician is a resource for you in helping to figure out what is normal for your child. Other pieces of the puzzle may be filled in by talking to your child's teacher or daycare provider, other parents, relatives, or a school administrator or counselor.
Answering the question of what to do about a particular behavior or emotional reaction will always involve trying to determine if it is a major or minor problem, if it is a part of normal and expected development, and if it is affecting multiple areas of a child's life. I hope, as you struggle through the ups and downs of parenting, this gives you some ideas about how to think clearly about your child.
Wednesday, September 14, 2011
Help Your Child Remember "You are Loved!"
"My teacher never calls on me when I raise my hand." "When I got back from the bathroom everyone was doing a new assignment and I didn't know what to do." "No one would play with me at recess." "I didn't have time to eat my lunch."
You can't be with your child all the time any more, and that can be hard for her and for you. Some children, and parents, have to be very brave to make it through each school day. It's time to remind yourself that an appropriate amount of independence and successful, gradual, separation from you will help your son or daughter become more confident, with higher self-esteem. However, as you ponder these theories, you still need a way to get both of you through the school day.
I don't have all the answers, but I do have some ideas. Some books for children address this topic in an appealing, caring way. I found the following books amazingly helpful:
The Invisible String, by Patrice Karst, describes in a touching simple way how we can be connected to each other by an invisible string of love, even when we are apart. Two children are woken by a thunder storm and run to find their mother. On each page the family explores how they are linked to different people they love.
The Kissing Hand, by Audrey Penn, stars a baby raccoon who doesn't want to go to school, but would rather stay home with his mommy and familiar toys. His mother kisses the palm of his hand and tells him that if he puts his hand up to his cheek he will feel her love any time he wants. The story is sweet, and concept easy to understand at almost any age.
Wemberly Worried, by Kevin Henkes, is about a little mouse who can't go anywhere without his special blanket. His mother comes up with a creative solution so he can secretly take his blankie whereever he goes.
After the first week of school my youngest daughter and I read The Invisible String together. We made red construction paper hearts, exchanged lipstick kisses imprinted on the hearts, and put them onto necklaces of string to wear the next day. In this way we can carry a tangible symbol of love, that hopefully will carry us through until we can be together again. Maybe some of you will see me with my "heart on a string" tomorrow in the office.
I would love to hear comments on book suggestions or ideas you have to help with separation anxiety, or other special traditions you have that help you feel closer when you have to be apart! Maybe you can find some books about children and their fathers, too. Good luck.
Monday, September 12, 2011
What to do with a Fever
Fevers are common in children. They are probably the number one reason for after hour phone calls to the doctor. Many parents feel panicky when the thermometer indicates fever. So what should you do?
First, and most important, don't panic! Keep trying to think logically and stay calm. Your sick child needs you to be able to make rational decisions. Understand that if the temperature is under 100.5 F, then it is not actually a fever, and you should simply monitor the situation. Also remember that fever can be helpful in fighting some infections.
Fever is a sign that your child's body is reacting to an infection. When there is a fever we try to figure out if the infection is a serious one. The fever itself won't hurt your child, but a serious infection can be a cause for concern. If your child has a fever, but is older than three months of age and is looking and acting just fine, you do not automatically need to call the doctor. Fairly normal behavior and energy level often mean the fever is caused by a more minor infection.
Here are some things to think about. If your child is under three months of age and has a rectal temperature of 100.5 or higher, you should probably call the doctor. You could consider unwrapping your baby, making sure that too many blankets isn't the problem. In general, though, for an infant under three months old with a fever, you should call.
If your child is over three months of age, then her behavior and appearance are important in evaluating how serious of an infection it is. There is no automatic temperature at which you should "panic" and rush to the ER. 103, 104, and 105 F are all "high" fevers. When the fever is high you also need to consider how sick your child looks. If they are very irritable or lethargic, it is more concerning.
When I am called about a child's high fever I frequently ask parents to give a dose of ibuprofen or acetaminophen, and then reassess their child in an hour. If she feels and looks much better with such a simple intervention, then it may be ok to wait until the next day before bringing her in. The goal of using anti-fever medicine is not to bring the temperature back down to normal, but to temporarily bring it down a little and to make your child feel better. It is a good sign if something basic like acetaminophen or ibuprofen can make a big difference in how your child feels.
Giving a cold bath is kind of dramatic and old-fashioned. I don't usually recommend it because I don't think it would be very soothing to already feel awful with a high fever and then get plunged into icy water. Cool wet washcloths on the forehead and back of the neck will be much more comfortable for your child.
106 F or higher makes me think of heat stroke, so at that level you should call or take your child to the hospital. 103 F and higher, in addition to a lethargic or irritable child who does not improve with acetaminophen or ibuprofen, would be another reason to call or have your child evaluated right away.
In addition, with any level of fever (that's 100.5 or higher) when your child is also very irritable or lethargic and not improving with anti-fever medicines, you should consider calling or taking your child in.
A child who is lethargic and irritable is usually not smiling, not eating and drinking, is very sleepy or won't stop crying or moaning. The child can be very restless or almost impossible to comfort and console. When the doctor asks about "lethargic" she does not mean that your child just wants to sit around and watch TV, or that they seem a little more tired than usual.
When there is a fever, this is what you should do:
Before you call the doctor, take a few seconds to think clearly about your child and his fever. What other symptoms does he have? What illnesses was he exposed to? How long has he been sick? Can you help him cool off by undressing him, using cool cloths on the forehead and neck, and giving him anti-fever medicine? Did you give the right amount of ibuprofen or acetaminophen, and did you give the medicine enough time to work? Was there improvement in his appearance, mood, discomfort, and energy level?
If you are reassured by improvement in your feverish child's appearance, then you may be able to manage this at home for the time being. You could make an appointment in the next day or two if the fever doesn't go away. If you continue to be quite concerned and worried about your child even after trying some things to help them feel better, then don't wait to check in with the doctor.
Disclaimer: As usual, my advice in this blog is general and may not apply to your specific situation, or to your child's special circumstances. This blog is not intended to be a substitute for the personal attention your own doctor can provide.
First, and most important, don't panic! Keep trying to think logically and stay calm. Your sick child needs you to be able to make rational decisions. Understand that if the temperature is under 100.5 F, then it is not actually a fever, and you should simply monitor the situation. Also remember that fever can be helpful in fighting some infections.
Fever is a sign that your child's body is reacting to an infection. When there is a fever we try to figure out if the infection is a serious one. The fever itself won't hurt your child, but a serious infection can be a cause for concern. If your child has a fever, but is older than three months of age and is looking and acting just fine, you do not automatically need to call the doctor. Fairly normal behavior and energy level often mean the fever is caused by a more minor infection.
Here are some things to think about. If your child is under three months of age and has a rectal temperature of 100.5 or higher, you should probably call the doctor. You could consider unwrapping your baby, making sure that too many blankets isn't the problem. In general, though, for an infant under three months old with a fever, you should call.
If your child is over three months of age, then her behavior and appearance are important in evaluating how serious of an infection it is. There is no automatic temperature at which you should "panic" and rush to the ER. 103, 104, and 105 F are all "high" fevers. When the fever is high you also need to consider how sick your child looks. If they are very irritable or lethargic, it is more concerning.
When I am called about a child's high fever I frequently ask parents to give a dose of ibuprofen or acetaminophen, and then reassess their child in an hour. If she feels and looks much better with such a simple intervention, then it may be ok to wait until the next day before bringing her in. The goal of using anti-fever medicine is not to bring the temperature back down to normal, but to temporarily bring it down a little and to make your child feel better. It is a good sign if something basic like acetaminophen or ibuprofen can make a big difference in how your child feels.
Giving a cold bath is kind of dramatic and old-fashioned. I don't usually recommend it because I don't think it would be very soothing to already feel awful with a high fever and then get plunged into icy water. Cool wet washcloths on the forehead and back of the neck will be much more comfortable for your child.
106 F or higher makes me think of heat stroke, so at that level you should call or take your child to the hospital. 103 F and higher, in addition to a lethargic or irritable child who does not improve with acetaminophen or ibuprofen, would be another reason to call or have your child evaluated right away.
In addition, with any level of fever (that's 100.5 or higher) when your child is also very irritable or lethargic and not improving with anti-fever medicines, you should consider calling or taking your child in.
A child who is lethargic and irritable is usually not smiling, not eating and drinking, is very sleepy or won't stop crying or moaning. The child can be very restless or almost impossible to comfort and console. When the doctor asks about "lethargic" she does not mean that your child just wants to sit around and watch TV, or that they seem a little more tired than usual.
When there is a fever, this is what you should do:
Before you call the doctor, take a few seconds to think clearly about your child and his fever. What other symptoms does he have? What illnesses was he exposed to? How long has he been sick? Can you help him cool off by undressing him, using cool cloths on the forehead and neck, and giving him anti-fever medicine? Did you give the right amount of ibuprofen or acetaminophen, and did you give the medicine enough time to work? Was there improvement in his appearance, mood, discomfort, and energy level?
If you are reassured by improvement in your feverish child's appearance, then you may be able to manage this at home for the time being. You could make an appointment in the next day or two if the fever doesn't go away. If you continue to be quite concerned and worried about your child even after trying some things to help them feel better, then don't wait to check in with the doctor.
Disclaimer: As usual, my advice in this blog is general and may not apply to your specific situation, or to your child's special circumstances. This blog is not intended to be a substitute for the personal attention your own doctor can provide.
Saturday, June 11, 2011
Raw Milk? You're kidding, right?
Pasteurization of milk is a fairly simple process that involves heating milk to about 160 degrees for 20 seconds. This important step in processing milk kills serious, disease-causing bacteria such as Salmonella, E.coli, and Campylobacter jejuni. Yes, E.coli is the same bacteria causing serious illness and death in Europe right now from contaminated bean sprouts.
Before milk was routinely pasteurized (in the 1920s) it caused many illnesses in our population, such as tuberculosis, typhoid fever, streptococcal infections, diphtheria, and more. In the early 1900s some smart mothers realized the dangers of raw milk and pasteurized it themselves by boiling it before feeding it to their children!
As a Peace Corps Volunteer in Honduras in the 1980s I noticed the villagers where I lived always boiled their milk before consuming it. We ate our cornflakes with hot milk! Although they lived in mud huts, with dirt floors, thatched roofs, and chickens and pigs running in and out all day long, these people would not touch milk that had not been heated properly. At the time I didn't understand the significance of this practice. Now I do.
Why would anyone want to drink milk that has potentially been contaminated with serious germs like E.coli? Good question! Those who do consume raw milk believe it comes from healthy animals, and is handled safely enough that it won't contain disease-causing bacteria. This is actually very difficult to guarantee. Even if the animal is healthy, its fecal matter can get into milk. This can be because it is on the udders, in the barn, on the hands of the farmers, or on insects or rodents living where the animals live. The germs are microscopic. Testing the milk is not comprehensive enough to ensure its safety.
Some people believe there are healthy enzymes and vitamins in the raw milk that are destroyed when the milk is heated. While it is true that heating does inactivate some enzymes and reduce vitamin C content, these are not important nutrients for humans to obtain from cows or animals other than humans. Raw milk has not been shown to reduce diabetes, asthma, or allergies. Nor does it improve your immune system. Raw human milk given directly from a mother to her child is completely different. We are not cows or goats.
Some people may believe that raw milk has helped their own individual health, but this is what is called testimonial or anecdotal evidence. It is a claim made by a few, and it is not supported by scientific, or research based evidence.
The images that come to my mind when I think about drinking raw milk are the following: eating strawberries without washing them, using the toilet or changing the kitty litter box and then preparing a meal for your family without washing your hands, simply cutting up the lettuce for a salad without thoroughly rinsing it first, changing a poopy diaper and then sitting down to lunch, eating bean sprouts in Germany... It nauseates me, repulses me, and makes me shudder to think about taking a sip of milk that has not been pasteurized.
The diseases you can catch from raw milk are serious. E.coli can kill. Certain types of E.coli can cause kidney failure, damage to the red blood cells, and stroke. In my pediatric training I cared for a preschool aged child who died of a stroke that occurred from complications of an E.coli infection. It was devastating. Since I have been in private practice I have had entire families become seriously ill from Campylobacter jejuni that originated in raw milk.
I don't think drinking raw milk is a smart decision for an adult, but it is certainly their choice to consume it. When it comes to our precious children I don't think we should putting them at risk by taking our health practices back a CENTURY and giving them raw milk. I don't think my pediatric practice would be very successful if I practiced 19th century medicine, so I have to recommend against the antiquated and dangerous fad of consuming raw milk.
Yuck.
Here are some links to give you more details. One link will take you to some testimonials that share experiences some people have had getting sick from raw milk, rather than typical anecdotes that tout the benefits of raw milk.
http://www.cdc.gov/features/rawmilk/
http://www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html
http://www.cdc.gov/foodsafety/rawmilk/raw-milk-questions-and-answers.html
http://www.cdc.gov/foodsafety/rawmilk/raw-milk-videos.html
Monday, May 30, 2011
Treating and Avoiding Seasonal Allergy Symptoms
 |
| This is what is in my medicine cabinet at home |
This all started for her when she was about four. I came home after work and she was running frantically around the house rubbing her eyes and bumping into things. Her eyelids were so puffy she could hardly see out of them. It was then I realized I needed to take a more pro-active approach toward her allergies. I needed to keep them under control, to not allow things to get so bad again.
Sometimes I have families come in to the office season after season, surprised that their children have allergy symptoms again! Parents sometimes don't want to keep their children on medication all the time. They don't like medication, and don't think it's healthy for their child to take "so much."
I think, if these parents had allergies themselves and knew what it was like, they would just go ahead and give the medicine and never allow things to get so bad for their child. It is simply miserable to be itchy, sneezy, congested, with a constant runny nose or post-nasal drip.
You can do some simple things at home to help your child with seasonal allergies:
- Keep their bedroom windows closed during allergy season so the pollen doesn't get into their bedding and clothes.
- Bathe them and wash their hair in the evening if they have been playing outside all day during allergy season. This will wash off some of the pollen so they don't breathe it all night.
- If you have air conditioning consider using it during allergy season.
- Give your child a simple over the counter antihistamine such as loratadine (Claritin) or cetirizine (Zyrtec). Either of these will last 24 hours, have few side effects, and work great especially to prevent allergy symptoms. Even fexofenadine (Allegra) is now available without a prescription, but it is still pretty expensive and must be dosed twice a day. These medications will work best if you give them regularly during your child's allergy season.
- If eye symptoms are really bad you can rinse your child's eyes gently with some saline solution, and then use over the counter allergy eye drops regularly to prevent symptoms. Two of the drops I know you can buy without a prescription are Zaditor and Patanol.
- An occasional dose of diphenhydramine (Benadryl) can go a long way if things get out of control and you have to get the symptoms calmed down for the night.
So, don't be surprised if the allergy symptoms your child had last spring come back again this year! The same holds true for fall allergies. Go ahead and treat your child's symptoms and help prevent the symptoms during the entire season your child usually has trouble.
Allowing your child to suffer through the allergies does NOT make their immune system better able to fight the allergies! It just makes them feel terrible.
If you want to do something to try to actually reduce or eliminate the allergies you will have to talk to an allergist about immunotherapy. This is a long-term (2-5 years?) endeavor of year-round weekly or biweekly allergy shots. To many kids (depending upon their age and tolerance), this treatment would be worse than taking some antihistamine for a few weeks or months each spring (or fall).
Monday, May 23, 2011
Why Do Doctors Run Late Part II
This is part two on why doctors run late in the office—more specifically, why I might run late some day while you are waiting for me! The same scenarios I presented in the blog last week are explained here in more detail. I am trying to make you understand why things aren’t always simple when it comes to keeping to a schedule.
Please understand, I am not trying to excuse myself for running late. Hardly anything causes me as much stress as getting behind on my schedule and forcing others to wait for me. I always strive to keep to my schedule by having appointments scheduled in a way that allows enough time for the problem and number of patients to be seen in a time slot. I try to be efficient during the appointment. I even ask people to reschedule—especially if they are so late for a check-up (or similar non-urgent appointment) that almost all of the allotted time has gone by before they arrive.
I have had people give me analogies such as getting their muffler fixed, oil changed, or brakes replaced on their car—for these procedures they are given an appointed time, and apparently their mechanic sticks to the schedule. My first response to this is that people aren’t cars! People talk back to me, and have opinions and feelings about what is happening to them. Secondly, it is unlikely there would be an emergency repair a mechanic would have to make immediately (when they thought they would just be simply replacing the muffler). And finally, in my experience, mechanics haven’t been very good at sticking to the schedule when it comes to fixing any of my cars. Or what about any other appointment you have had scheduled, such as getting your hair cut? Your stylist can keep to her schedule, right? Again, a doctor’s appointment isn’t the same as getting your hair cut. Much is known ahead of time about what will happen in the salon (making scheduling more accurate), but the flow of an appointment with your doctor is often unpredictable.
So here are my scenarios—with more detail to give you an idea of why I often must just deal with the problem as it comes up, instead of cutting people off or making them reschedule an appointment. And I’m not even including the little things—such as the newly potty trained three year old who has to go to the bathroom in the middle of the appointment, or the child who vomits everywhere as soon as I walk in the room, or the adolescent who faints after her immunization, or the poopy diaper that goes up the back and onto the exam table.
1. My first patient of the morning is seven minutes late. She is sick and there are no other appointments available until after hours. The child cannot drive herself to the office and I don’t feel right about penalizing her because her parent did not make it to the office on time. It turns out the reason the parent was late is because the child was vomiting all over the place before getting in the car—the best laid plans to arrive at the office on time went awry due to unpredictable circumstances. Or, there was an accident and traffic was re-routed, causing the drive to take longer than usual. Or, the roads were icy. Or, they were just late—but it really isn’t the fault of the 5 year old with the high fever.
2. An appointment was given for one child, but it turns out the sibling is also ill and needs to be seen. Mom is looking stressed and near tears, she won’t have a car that afternoon to bring the sibling back. I don’t have the chart, and have to request it. This is a really common scenario. I am asked to see siblings, or “just take a quick look in the ears,” or “just answer a quick question about brother’s potty training” many times throughout the day. How would you feel if you were in this Mom’s position? I don’t think you would be very happy if your pediatrician said “No, I’m sorry Mrs. Smith, next time you should think ahead and schedule another appointment for little Johnny. Have a nice day.” It would help me if parents could alert my nursing or front desk staff ahead of time so I could have the sibling’s chart, and so I could be aware from the onset that I must divide my time between two kids instead of using all the time for one. But it’s not very likely that I am going to refuse to see a sibling if it is for a simple illness such as a potential ear infection. Adding on another child (or even just a conversation about another child) at the end of the first child’s appointment may take an extra five to ten minutes. If I know about it ahead of time I can be more efficient.
3. A middle-school student is in the office for a sore throat. I do a brief history and physical exam, get a throat swab, and step out while the test runs. I return to inform the family the child has strep, discuss the illness, and write the prescription. I write a note to excuse the student from school, and another to explain the parent’s absence from work. As I get up to leave the parent asks their child to step out because they want to discuss something privately with the doctor. At this point I had thought we were finished with the appointment. But the conversation reveals that the patient is having some serious mental health problems and the parent needs some advice TODAY. This part of the visit turns out to be more important than the strep throat, and yes, it will put me 10 to 15 minutes behind in my schedule. Again, if I had known ahead of time I could have planned better—perhaps having this discussion while we waited for the strep test to run—but I can’t turn this person away just because the problem wasn’t scheduled into my day.
4. A teenager was given a ten minute appointment for the primary complaint of a sore throat. When I get to the room she tells me that she was too embarrassed to say anything to the receptionist, but actually she is having problems with her periods. By the way, she has also recently become sexually active, and is worried about STDs and pregnancy prevention. Obviously we could have allotted more time if we had known all of these issues, but isn’t it understandable why she had trouble telling this to the receptionist? Maybe her dad made the appointment for her, and he is sitting in the waiting room right now wondering if she has strep throat or mono. Meanwhile I am having a completely different conversation with his daughter. And then I will have to reach an agreement with the teenager about how we are going to talk about this with her dad, then dad has to come in and we have another conversation. This will add 15 to 20 minutes to the scheduled 10 minute appointment.
5. A two year old is in the office at 2pm because of two to three days of fever and fatigue. The usual ten minute time slot was allotted for this basic, acute illness. During the exam it quickly becomes apparent she will need to be hospitalized. She is so pale and lethargic that it is clear something is seriously wrong. Now it is 2:12pm (her appt. technically ended at 2:10). I must arrange for her hospital admission. This will involve conferring with my office staff (five minutes), possibly collaborating with another doctor at my office to inform them of the admission and get their opinion (five to ten minutes), talking with other doctors and nurses at the hospital (minimum of ten minutes, may involve more than one phone call), and discussing the possible diagnosis with the child’s family and explaining the diagnostic and treatment plan to them (ten-twenty minutes). Now I am ending this child’s appointment at least 30 minutes (up to 50 minutes) after it had been scheduled to end. To those who are waiting, and feeling frustrated and annoyed, all I can say here is that I would give your child the same time and attention if they were seriously ill.
6. Another scenario is the “by the way, doctor” that is added on as I am walking out the door. This could be a list of questions from the patient who hardly ever comes into the office, is here today, and needs some answers. Or, it could be a behavioral question about a preschooler, or a potty training question for a two year old. It could be questions regarding when to think about ADHD, school problems, how to handle a child’s grief over their grandparent’s death, how to help a child through their parents’ divorce, what to do about bed-wetting/constipation/soiling the underpants, how to get a child to sleep better, etc. Many parents wouldn’t think of making a separate appointment for these questions, but they are important topics that will take at least a few minutes of my time. It is always helpful if a parent can help me plan the time in the office visit by saying at the beginning of the appointment something like: “We are here because we suspect an ear infection, but I also wanted to ask you a question about potty training.” Or, “we made the appointment for back pain, but we have seven other things on our list to ask you about.” For those with a long list I will probably then ask them to prioritize in order of importance, and tell them at the beginning that they have a ten minute appointment and we may have to reschedule to discuss some of the other problems. If I don’t know about the list until I am finished evaluating the primary complaint it affects my schedule more.
I think there were at least four more scenarios in my original blog on this topic. There is enough here, however, to give you a general idea of how and why I can get off schedule. There are also some things you can do to help me stay on schedule. These would include providing accurate information to the scheduler about the main reason, and any other secondary reasons, for the appointment (including how long the symptoms have been present), letting me know at the beginning of the appointment about everything you want to discuss, and informing my office staff that you are planning to have me check a sibling in addition to the child who originally was scheduled for an appointment.
To those of you who simply cannot tolerate waiting, or who have such a tight schedule that it isn’t possible to run late, you might consider booking your appointments as early as possible in the morning or first thing in the afternoon. In general it is more likely I will be running behind as it gets to be later in the day. And my pledge to you is that I will continue to work on staying on schedule and being efficient during my office day—while still striving to treat each patient as an individual who may have important and unexpected needs. Ultimately I will try to treat each family as I would want someone to handle my own.
Please understand, I am not trying to excuse myself for running late. Hardly anything causes me as much stress as getting behind on my schedule and forcing others to wait for me. I always strive to keep to my schedule by having appointments scheduled in a way that allows enough time for the problem and number of patients to be seen in a time slot. I try to be efficient during the appointment. I even ask people to reschedule—especially if they are so late for a check-up (or similar non-urgent appointment) that almost all of the allotted time has gone by before they arrive.
I have had people give me analogies such as getting their muffler fixed, oil changed, or brakes replaced on their car—for these procedures they are given an appointed time, and apparently their mechanic sticks to the schedule. My first response to this is that people aren’t cars! People talk back to me, and have opinions and feelings about what is happening to them. Secondly, it is unlikely there would be an emergency repair a mechanic would have to make immediately (when they thought they would just be simply replacing the muffler). And finally, in my experience, mechanics haven’t been very good at sticking to the schedule when it comes to fixing any of my cars. Or what about any other appointment you have had scheduled, such as getting your hair cut? Your stylist can keep to her schedule, right? Again, a doctor’s appointment isn’t the same as getting your hair cut. Much is known ahead of time about what will happen in the salon (making scheduling more accurate), but the flow of an appointment with your doctor is often unpredictable.
So here are my scenarios—with more detail to give you an idea of why I often must just deal with the problem as it comes up, instead of cutting people off or making them reschedule an appointment. And I’m not even including the little things—such as the newly potty trained three year old who has to go to the bathroom in the middle of the appointment, or the child who vomits everywhere as soon as I walk in the room, or the adolescent who faints after her immunization, or the poopy diaper that goes up the back and onto the exam table.
1. My first patient of the morning is seven minutes late. She is sick and there are no other appointments available until after hours. The child cannot drive herself to the office and I don’t feel right about penalizing her because her parent did not make it to the office on time. It turns out the reason the parent was late is because the child was vomiting all over the place before getting in the car—the best laid plans to arrive at the office on time went awry due to unpredictable circumstances. Or, there was an accident and traffic was re-routed, causing the drive to take longer than usual. Or, the roads were icy. Or, they were just late—but it really isn’t the fault of the 5 year old with the high fever.
2. An appointment was given for one child, but it turns out the sibling is also ill and needs to be seen. Mom is looking stressed and near tears, she won’t have a car that afternoon to bring the sibling back. I don’t have the chart, and have to request it. This is a really common scenario. I am asked to see siblings, or “just take a quick look in the ears,” or “just answer a quick question about brother’s potty training” many times throughout the day. How would you feel if you were in this Mom’s position? I don’t think you would be very happy if your pediatrician said “No, I’m sorry Mrs. Smith, next time you should think ahead and schedule another appointment for little Johnny. Have a nice day.” It would help me if parents could alert my nursing or front desk staff ahead of time so I could have the sibling’s chart, and so I could be aware from the onset that I must divide my time between two kids instead of using all the time for one. But it’s not very likely that I am going to refuse to see a sibling if it is for a simple illness such as a potential ear infection. Adding on another child (or even just a conversation about another child) at the end of the first child’s appointment may take an extra five to ten minutes. If I know about it ahead of time I can be more efficient.
3. A middle-school student is in the office for a sore throat. I do a brief history and physical exam, get a throat swab, and step out while the test runs. I return to inform the family the child has strep, discuss the illness, and write the prescription. I write a note to excuse the student from school, and another to explain the parent’s absence from work. As I get up to leave the parent asks their child to step out because they want to discuss something privately with the doctor. At this point I had thought we were finished with the appointment. But the conversation reveals that the patient is having some serious mental health problems and the parent needs some advice TODAY. This part of the visit turns out to be more important than the strep throat, and yes, it will put me 10 to 15 minutes behind in my schedule. Again, if I had known ahead of time I could have planned better—perhaps having this discussion while we waited for the strep test to run—but I can’t turn this person away just because the problem wasn’t scheduled into my day.
4. A teenager was given a ten minute appointment for the primary complaint of a sore throat. When I get to the room she tells me that she was too embarrassed to say anything to the receptionist, but actually she is having problems with her periods. By the way, she has also recently become sexually active, and is worried about STDs and pregnancy prevention. Obviously we could have allotted more time if we had known all of these issues, but isn’t it understandable why she had trouble telling this to the receptionist? Maybe her dad made the appointment for her, and he is sitting in the waiting room right now wondering if she has strep throat or mono. Meanwhile I am having a completely different conversation with his daughter. And then I will have to reach an agreement with the teenager about how we are going to talk about this with her dad, then dad has to come in and we have another conversation. This will add 15 to 20 minutes to the scheduled 10 minute appointment.
5. A two year old is in the office at 2pm because of two to three days of fever and fatigue. The usual ten minute time slot was allotted for this basic, acute illness. During the exam it quickly becomes apparent she will need to be hospitalized. She is so pale and lethargic that it is clear something is seriously wrong. Now it is 2:12pm (her appt. technically ended at 2:10). I must arrange for her hospital admission. This will involve conferring with my office staff (five minutes), possibly collaborating with another doctor at my office to inform them of the admission and get their opinion (five to ten minutes), talking with other doctors and nurses at the hospital (minimum of ten minutes, may involve more than one phone call), and discussing the possible diagnosis with the child’s family and explaining the diagnostic and treatment plan to them (ten-twenty minutes). Now I am ending this child’s appointment at least 30 minutes (up to 50 minutes) after it had been scheduled to end. To those who are waiting, and feeling frustrated and annoyed, all I can say here is that I would give your child the same time and attention if they were seriously ill.
6. Another scenario is the “by the way, doctor” that is added on as I am walking out the door. This could be a list of questions from the patient who hardly ever comes into the office, is here today, and needs some answers. Or, it could be a behavioral question about a preschooler, or a potty training question for a two year old. It could be questions regarding when to think about ADHD, school problems, how to handle a child’s grief over their grandparent’s death, how to help a child through their parents’ divorce, what to do about bed-wetting/constipation/soiling the underpants, how to get a child to sleep better, etc. Many parents wouldn’t think of making a separate appointment for these questions, but they are important topics that will take at least a few minutes of my time. It is always helpful if a parent can help me plan the time in the office visit by saying at the beginning of the appointment something like: “We are here because we suspect an ear infection, but I also wanted to ask you a question about potty training.” Or, “we made the appointment for back pain, but we have seven other things on our list to ask you about.” For those with a long list I will probably then ask them to prioritize in order of importance, and tell them at the beginning that they have a ten minute appointment and we may have to reschedule to discuss some of the other problems. If I don’t know about the list until I am finished evaluating the primary complaint it affects my schedule more.
I think there were at least four more scenarios in my original blog on this topic. There is enough here, however, to give you a general idea of how and why I can get off schedule. There are also some things you can do to help me stay on schedule. These would include providing accurate information to the scheduler about the main reason, and any other secondary reasons, for the appointment (including how long the symptoms have been present), letting me know at the beginning of the appointment about everything you want to discuss, and informing my office staff that you are planning to have me check a sibling in addition to the child who originally was scheduled for an appointment.
To those of you who simply cannot tolerate waiting, or who have such a tight schedule that it isn’t possible to run late, you might consider booking your appointments as early as possible in the morning or first thing in the afternoon. In general it is more likely I will be running behind as it gets to be later in the day. And my pledge to you is that I will continue to work on staying on schedule and being efficient during my office day—while still striving to treat each patient as an individual who may have important and unexpected needs. Ultimately I will try to treat each family as I would want someone to handle my own.
Subscribe to:
Posts (Atom)