As if you didn’t already know, there are things you probably don’t like about taking your kids to the doctor. They’re the same things you don’t like about going to your own doctor. And what I know when I go to my own doctor.
►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. (Every phone message in a medical office starts with “If this is a medical emergency, hang up and call 911.” I have to assume that if you’ve read even this far, you can see the reason for it. My office is no exception.)
Almost every other doctor’s office gives you some permutation of the following. Maybe it’s a phone tree of buttons and choices just so you can then enter the phone number on which you want someone to call you back. Or a different phone number to call for an answering service that might or might not answer, that might or might not pass on your message (or the right message) to the doctor on call. The latest variation on this theme is an 800 number, sometime invisibly hidden in an automatic forwarding system from the office number, to a generally very well qualified registered nurse in Iowa who can answer most questions very well. To get the nurse, you probably have to leave a message, and that service will probably call you back. If they’re busy answering calls from all over the country, the callback might take a while, however. Even if you call the number and page the doctor, the odds of speaking to your doctor are slim in most practices. Even that is only helpful if the doctor actually knows who you are.
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 (hopefully they had an adult with them) there may not be anyone to take them to the doctor until a caregiver returns from work.
As every parent knows, babies always seem to get sick or have problems at night. (I would point out, by the way, that coughs always get worse at night and fevers always go up 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 put distance between them and their patients. It seems to be generally accepted that your doctor is somebody who exists just in the office, and that patients, whether adults or children, are on their own otherwise.
When I first moved to California in the 1990s, I wanted to have a home in which I could live in the house and convert 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 not being allowed in residential areas. Where do they think the sick people live?
I think this is one of the most striking things I have learned. When people actually have complete access to their doctor, they use this access less, not more. The reason, I suspect, is that they are more willing to stick it out if they know they can reach the doctor if they need to. So there isn’t such a rush to call at the first sign of illness if you know that the doctor will talk to you or see your child—if really needed—at night or on the weekend.
►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. Pediatric 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. (You see, 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.
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.
Often, parents in these practices will bring up something really important just as the doctor is leaving the room, or even in the middle of a visit for another reason. The doctor will say that’s cause to come back for another visit. 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. (Here’s another aside, for parents. This is usually the reason your youngest is acting out towards mom while she’s on the phone/visiting with somebody/interacting with a sibling or spouse. When kids think that there might not be another opportunity to get mom’s attention, they try to get that attention immediately, even if not in the best way.)
Your insurance company doesn’t care if the visit takes 2 minutes or 20 minutes. That practice is still going to get the same payment. There’s a code word I want you to know that you’ll be seeing in the press. Efficiency. Many health-providing businesses are rewarding doctors (paying them more) 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: a computer can count how many appointments there were, and the same computer can see how much time was taken to fit all those appointments in.
All the things I value, maybe you too, are not so 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 for 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 few 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 you, even if they’re open about not knowing for sure.
►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 sight. 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. There’s always that extra 15 seconds, I suppose.
From a medical point of view, the demeanor of children is hard to gauge when they’re livid for other reasons. Forget about hearing a heart murmur or a subtle change in breathing. It’ll be hard to get them to walk or talk on command. There is no definitive medical study that I have seen which shows that taking more time in a visit results in healthier children. I suspect that with a careful enough measure, there would be a benefit.
But I wonder what the studies didn’t measure. Things like being terrified of going to the doctor, perhaps lifelong. Maybe they won’t want to take medicine that they really need. Maybe the doctor will miss something that could have been found earlier if the kid hadn’t been experiencing a physician-induced demonic possession. That leaves out how much more pleasant the whole process is if the kid likes the doctor. A mother recently told me that her school-age child was upset that his baby brother got to come to my office without him. 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. Isn’t that the way it’s supposed to be?
►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. (Though it might cost you more than going to the doctor.) But what if you needed new piping throughout the house, or else something 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? Some problems need a plumber. But some problems need your plumber.
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 has gone away, but then a few weeks later it’s 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 and accurately enough say that the child’s lungs sound normal and give 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 that continuity of care is shockingly undervalued in assessments of medical care. There’s an important advantage to seeing the same doctor every time, for well visits and sick visits. It’s the same doctor you get to talk to on the phone when you call. I know who your child is, I know where you live and what resources might be nearby. I know that your child has serious issues with taking medicine, or has a history of certain types of problems. So when you call and say that it’s starting again, you might not have to start from scratch with the story. You won’t have to sell your concerns to the doctor on call in order to have those issues taken seriously.
My job is only occasionally to prescribe something for a generic ear infection. My job is to make your child’s life better.
And by the way...
There are a lot of nice things about living here in Berkeley, California. One of these is the availability of every different manner of medical care. Some kinds of care would be considered ‘alternative’ in some places, but is common here. Traditionally-trained doctors like me have just as wide-ranging an approach as any other group of people here. As good scientific evidence has emerged supporting new approaches, I am often among the first to incorporate these into my practice. I have been using probiotics, for example, as my routine treatment for certain problems for more than a decade. I am trained in clinical hypnosis and have used it effectively in children as young as 5. I have made treating the child my goal, and not simply treating a diagnosis. This approach, I believe, is true ‘holistic’ medicine. All children need parents who are their advocates. As a physician, I am nearly powerless without the support of the parents. So I feel strongly that you need to find a physician for your child who you respect as an expert consultant. The physician you choose should have the qualities and approach you value. What’s the point of taking your kid to the doctor if you don’t trust the advice you get?
So let me put it bluntly. I don’t see unvaccinated children. If you don’t want to vaccinate your child, there is excellent pediatric care available in this area. Please go to one of those doctors. Not me. I believe so strongly in the value of vaccination, that I think you would be making a serious mistake by refusing. By ‘serious’ I mean leaving your child at risk for potentially devastating, lethal illness. These illnesses are around. Here in Northern California, where there is a high rate of vaccine refusal, there continue to be outbreaks of some of these bad diseases. Some schools where the vaccination rates are particularly low have been closed or quarantined by public health authorities. Kids and others have become sick, some have died. I would feel awful if your newborn baby caught one of these bad and yet preventable diseases from a visit to my office, because the previous kid who was in the office for a nonspecific fever was unvaccinated. I am uninterested in debating the issue. How can I counter your recollection of the opinions of an internet site, alarmist book or paranoid acquaintance, or what somebody you didn’t know told you at the farmer’s market? If you believe that someone you have met or heard about has more trustworthy expert knowledge about the health needs and illnesses of children, please, go to that person for your child’s care. I will not accept into my practice children who are unvaccinated.
My job is to make your child’s life better.