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Like Dancing Bears
I had just finished a full morning of seeing patients with a third-year medical student who was beginning his second clinical rotation. His half day with me was billed as an “Introduction to Outpatient Community Pediatrics.” And, I thought I had given him a pretty good run for his 3-hour investment.
We sat down in my cluttered but homey office for a brief recap of the morning's experience. Unless it is a question about a physical finding that will vanish when the patient leaves, I usually ask students to hold most of their questions until the end of the half-day session, when we can have a more leisurely opportunity to explore the answers. But, my young appendage for the morning had no questions, just an observation: “You certainly have your patients well trained.”
This was not the first time a visitor to my practice has made this comment. And each time I hear it, I get a bit uncomfortable … and defensive.
No question about it. I see patients more quickly than the average clinician. And, I'm not embarrassed to admit that my approach to problems, health-related or otherwise, is pragmatic, no-nonsense, get-to-the-point. I am old enough that I introduce myself to patients and parents as “Doctor Wilkoff.” That's what everyone did when I started, and I've seen no reason to change.
But, I hope I'm not an ogre. My coworkers don't snap to attention and click their heels when I enter the room. I ask people what is bothering them in a way that I hope encourages the best answers, and I listen to their responses. So, it troubles me when someone makes an observation that suggests that I have patients and parents performing like a troupe of dancing bears.
Struggling to sound undefensive, I asked “What do you mean by well-trained?!!” Seeing through my thin disguise, the student replied, “No, no, I didn't mean it that way. I was just impressed how many calls you received during your call time. And, I don't remember that we were interrupted once while we were seeing patients. You told one of your partners you only got one call last night.”
I replied, “I was hoping that's what you would say. You know that every physician's patients are trained. … We are all just slaves to positive and negative reinforcement. Our patients know they can always reach us at a call time and they know we keep our promises to call them in the morning. In that sense, they are 'trained' to wait.”
A physician who always runs late will find that when he is on time his patients will be late. The physician who instructs his staff to take temperatures on every sick child and makes a big deal about the number is training parents to focus on fever and call him with frequent updates about each tenth-of-a-degree change.
Physicians who include teething in their diagnostic repertoires and fail to correct parents who use teething as an explanation for a variety of symptoms may be training those parents to be less accurate and safe observers of their children. The physician who is less than rigorous with his diagnostic criteria for otitis and/or who treats when observation would be a better course is training parents to expect a diagnosis and antibiotics when their children have fevers and runny noses.
I could have given my young tutee even more examples of how parent/patient behavior is a reflection of their physicians' behavior. But, it was pushing 12 o'clock and our patients are trained that for the next hour they can reach me, and that I'll be on my bicycle and out of breath when I answer my pager.
I had just finished a full morning of seeing patients with a third-year medical student who was beginning his second clinical rotation. His half day with me was billed as an “Introduction to Outpatient Community Pediatrics.” And, I thought I had given him a pretty good run for his 3-hour investment.
We sat down in my cluttered but homey office for a brief recap of the morning's experience. Unless it is a question about a physical finding that will vanish when the patient leaves, I usually ask students to hold most of their questions until the end of the half-day session, when we can have a more leisurely opportunity to explore the answers. But, my young appendage for the morning had no questions, just an observation: “You certainly have your patients well trained.”
This was not the first time a visitor to my practice has made this comment. And each time I hear it, I get a bit uncomfortable … and defensive.
No question about it. I see patients more quickly than the average clinician. And, I'm not embarrassed to admit that my approach to problems, health-related or otherwise, is pragmatic, no-nonsense, get-to-the-point. I am old enough that I introduce myself to patients and parents as “Doctor Wilkoff.” That's what everyone did when I started, and I've seen no reason to change.
But, I hope I'm not an ogre. My coworkers don't snap to attention and click their heels when I enter the room. I ask people what is bothering them in a way that I hope encourages the best answers, and I listen to their responses. So, it troubles me when someone makes an observation that suggests that I have patients and parents performing like a troupe of dancing bears.
Struggling to sound undefensive, I asked “What do you mean by well-trained?!!” Seeing through my thin disguise, the student replied, “No, no, I didn't mean it that way. I was just impressed how many calls you received during your call time. And, I don't remember that we were interrupted once while we were seeing patients. You told one of your partners you only got one call last night.”
I replied, “I was hoping that's what you would say. You know that every physician's patients are trained. … We are all just slaves to positive and negative reinforcement. Our patients know they can always reach us at a call time and they know we keep our promises to call them in the morning. In that sense, they are 'trained' to wait.”
A physician who always runs late will find that when he is on time his patients will be late. The physician who instructs his staff to take temperatures on every sick child and makes a big deal about the number is training parents to focus on fever and call him with frequent updates about each tenth-of-a-degree change.
Physicians who include teething in their diagnostic repertoires and fail to correct parents who use teething as an explanation for a variety of symptoms may be training those parents to be less accurate and safe observers of their children. The physician who is less than rigorous with his diagnostic criteria for otitis and/or who treats when observation would be a better course is training parents to expect a diagnosis and antibiotics when their children have fevers and runny noses.
I could have given my young tutee even more examples of how parent/patient behavior is a reflection of their physicians' behavior. But, it was pushing 12 o'clock and our patients are trained that for the next hour they can reach me, and that I'll be on my bicycle and out of breath when I answer my pager.
I had just finished a full morning of seeing patients with a third-year medical student who was beginning his second clinical rotation. His half day with me was billed as an “Introduction to Outpatient Community Pediatrics.” And, I thought I had given him a pretty good run for his 3-hour investment.
We sat down in my cluttered but homey office for a brief recap of the morning's experience. Unless it is a question about a physical finding that will vanish when the patient leaves, I usually ask students to hold most of their questions until the end of the half-day session, when we can have a more leisurely opportunity to explore the answers. But, my young appendage for the morning had no questions, just an observation: “You certainly have your patients well trained.”
This was not the first time a visitor to my practice has made this comment. And each time I hear it, I get a bit uncomfortable … and defensive.
No question about it. I see patients more quickly than the average clinician. And, I'm not embarrassed to admit that my approach to problems, health-related or otherwise, is pragmatic, no-nonsense, get-to-the-point. I am old enough that I introduce myself to patients and parents as “Doctor Wilkoff.” That's what everyone did when I started, and I've seen no reason to change.
But, I hope I'm not an ogre. My coworkers don't snap to attention and click their heels when I enter the room. I ask people what is bothering them in a way that I hope encourages the best answers, and I listen to their responses. So, it troubles me when someone makes an observation that suggests that I have patients and parents performing like a troupe of dancing bears.
Struggling to sound undefensive, I asked “What do you mean by well-trained?!!” Seeing through my thin disguise, the student replied, “No, no, I didn't mean it that way. I was just impressed how many calls you received during your call time. And, I don't remember that we were interrupted once while we were seeing patients. You told one of your partners you only got one call last night.”
I replied, “I was hoping that's what you would say. You know that every physician's patients are trained. … We are all just slaves to positive and negative reinforcement. Our patients know they can always reach us at a call time and they know we keep our promises to call them in the morning. In that sense, they are 'trained' to wait.”
A physician who always runs late will find that when he is on time his patients will be late. The physician who instructs his staff to take temperatures on every sick child and makes a big deal about the number is training parents to focus on fever and call him with frequent updates about each tenth-of-a-degree change.
Physicians who include teething in their diagnostic repertoires and fail to correct parents who use teething as an explanation for a variety of symptoms may be training those parents to be less accurate and safe observers of their children. The physician who is less than rigorous with his diagnostic criteria for otitis and/or who treats when observation would be a better course is training parents to expect a diagnosis and antibiotics when their children have fevers and runny noses.
I could have given my young tutee even more examples of how parent/patient behavior is a reflection of their physicians' behavior. But, it was pushing 12 o'clock and our patients are trained that for the next hour they can reach me, and that I'll be on my bicycle and out of breath when I answer my pager.
Meet-and-Greets
It would be an exaggeration to say that I have a love-hate relationship with meet-and-greet visits. Let's just say that I know that it can be very important to sit down with families who are shopping for a pediatrician. But, these investigatory sessions can throw my office schedule into a waiting room gridlock from which it may take hours to recover. Meet-and-greet visits are never the high point of my day.
When one or both parents-to-be are former patients, the visits may take just a few minutes. Their own parents have brainwashed them into believing that I am the best thing since sliced bread. The young and clueless couples have already decided to come to our office, and I simply feed them a few answers to the questions they have forgotten to ask.
Sometimes an “interrogation” can drag on for 30 minutes as we walk slowly through a laser-printed set of questions collected from Internet sites and books about how to be a skeptical parent. We have tried to shortcut some of the predictable biographic and procedural questions by handing out a printed sheet of answers to these FAQs. But, from time to time a receptionist will forget to pass out these sheets and I must spin a few extra yarns to make myself appear to be human and well trained.
One of the standard questions asked is whether my wife and I have children. Obviously, they want to know that I have “been there and done that.” It's silly because we all know one doesn't have to have had children to be an excellent pediatrician. To further impress my interrogators, I often add the reassurance that none of my three offspring is currently incarcerated or institutionalized.
The most time-devouring questions are the open-ended ones such as, “Do you prescribe antibiotics?” or “How do you feel about immunizations?” “Yes” and “Good” never seem to be sufficient answers. But, I've learned to toss these questions back at my inquisitors. Their answers to, “How do you feel about antibiotics and immunizations?” will give me some clues about how easy this family would be to work with.
While I still have control of the questioning, I ask a few more: “Do you have a birth plan and what does it include?” “Do you plan to breast-feed and do you have any concerns about how it will work?” The answers can highlight potential friction points and bumps in the road that can make the first few weeks of parenting unnecessarily disappointing and frustrating for all of us.
It's nice to know ahead of time that a family is planning to refuse the vitamin K shot and/or antibiotic eye drops. At least I will have a chance to tell my side of the story in the calm and rational setting of my office. And, it's just plain good medicine to establish even a small foundation for your professional relationship before the doodoo hits the fan. The only time I have been sued in more than 30 years involved a premature newborn and a family from out of state whom I had never met. Even a brief prenatal visit might have helped me stay out of the courtroom.
I can still remember how much easier it was to tell a couple that I was sure that their brand-new daughter had Down syndrome because I had suffered through a 15-minute meet-and-greet the previous month. Unfortunately, we continue to have trouble getting our obstetricians to see much value in pediatric prenatal visits. They want us there in a flash when things go sour, but somehow they can't remember to encourage their patients to visit and choose a pediatrician in the calm of the second trimester.
It would be an exaggeration to say that I have a love-hate relationship with meet-and-greet visits. Let's just say that I know that it can be very important to sit down with families who are shopping for a pediatrician. But, these investigatory sessions can throw my office schedule into a waiting room gridlock from which it may take hours to recover. Meet-and-greet visits are never the high point of my day.
When one or both parents-to-be are former patients, the visits may take just a few minutes. Their own parents have brainwashed them into believing that I am the best thing since sliced bread. The young and clueless couples have already decided to come to our office, and I simply feed them a few answers to the questions they have forgotten to ask.
Sometimes an “interrogation” can drag on for 30 minutes as we walk slowly through a laser-printed set of questions collected from Internet sites and books about how to be a skeptical parent. We have tried to shortcut some of the predictable biographic and procedural questions by handing out a printed sheet of answers to these FAQs. But, from time to time a receptionist will forget to pass out these sheets and I must spin a few extra yarns to make myself appear to be human and well trained.
One of the standard questions asked is whether my wife and I have children. Obviously, they want to know that I have “been there and done that.” It's silly because we all know one doesn't have to have had children to be an excellent pediatrician. To further impress my interrogators, I often add the reassurance that none of my three offspring is currently incarcerated or institutionalized.
The most time-devouring questions are the open-ended ones such as, “Do you prescribe antibiotics?” or “How do you feel about immunizations?” “Yes” and “Good” never seem to be sufficient answers. But, I've learned to toss these questions back at my inquisitors. Their answers to, “How do you feel about antibiotics and immunizations?” will give me some clues about how easy this family would be to work with.
While I still have control of the questioning, I ask a few more: “Do you have a birth plan and what does it include?” “Do you plan to breast-feed and do you have any concerns about how it will work?” The answers can highlight potential friction points and bumps in the road that can make the first few weeks of parenting unnecessarily disappointing and frustrating for all of us.
It's nice to know ahead of time that a family is planning to refuse the vitamin K shot and/or antibiotic eye drops. At least I will have a chance to tell my side of the story in the calm and rational setting of my office. And, it's just plain good medicine to establish even a small foundation for your professional relationship before the doodoo hits the fan. The only time I have been sued in more than 30 years involved a premature newborn and a family from out of state whom I had never met. Even a brief prenatal visit might have helped me stay out of the courtroom.
I can still remember how much easier it was to tell a couple that I was sure that their brand-new daughter had Down syndrome because I had suffered through a 15-minute meet-and-greet the previous month. Unfortunately, we continue to have trouble getting our obstetricians to see much value in pediatric prenatal visits. They want us there in a flash when things go sour, but somehow they can't remember to encourage their patients to visit and choose a pediatrician in the calm of the second trimester.
It would be an exaggeration to say that I have a love-hate relationship with meet-and-greet visits. Let's just say that I know that it can be very important to sit down with families who are shopping for a pediatrician. But, these investigatory sessions can throw my office schedule into a waiting room gridlock from which it may take hours to recover. Meet-and-greet visits are never the high point of my day.
When one or both parents-to-be are former patients, the visits may take just a few minutes. Their own parents have brainwashed them into believing that I am the best thing since sliced bread. The young and clueless couples have already decided to come to our office, and I simply feed them a few answers to the questions they have forgotten to ask.
Sometimes an “interrogation” can drag on for 30 minutes as we walk slowly through a laser-printed set of questions collected from Internet sites and books about how to be a skeptical parent. We have tried to shortcut some of the predictable biographic and procedural questions by handing out a printed sheet of answers to these FAQs. But, from time to time a receptionist will forget to pass out these sheets and I must spin a few extra yarns to make myself appear to be human and well trained.
One of the standard questions asked is whether my wife and I have children. Obviously, they want to know that I have “been there and done that.” It's silly because we all know one doesn't have to have had children to be an excellent pediatrician. To further impress my interrogators, I often add the reassurance that none of my three offspring is currently incarcerated or institutionalized.
The most time-devouring questions are the open-ended ones such as, “Do you prescribe antibiotics?” or “How do you feel about immunizations?” “Yes” and “Good” never seem to be sufficient answers. But, I've learned to toss these questions back at my inquisitors. Their answers to, “How do you feel about antibiotics and immunizations?” will give me some clues about how easy this family would be to work with.
While I still have control of the questioning, I ask a few more: “Do you have a birth plan and what does it include?” “Do you plan to breast-feed and do you have any concerns about how it will work?” The answers can highlight potential friction points and bumps in the road that can make the first few weeks of parenting unnecessarily disappointing and frustrating for all of us.
It's nice to know ahead of time that a family is planning to refuse the vitamin K shot and/or antibiotic eye drops. At least I will have a chance to tell my side of the story in the calm and rational setting of my office. And, it's just plain good medicine to establish even a small foundation for your professional relationship before the doodoo hits the fan. The only time I have been sued in more than 30 years involved a premature newborn and a family from out of state whom I had never met. Even a brief prenatal visit might have helped me stay out of the courtroom.
I can still remember how much easier it was to tell a couple that I was sure that their brand-new daughter had Down syndrome because I had suffered through a 15-minute meet-and-greet the previous month. Unfortunately, we continue to have trouble getting our obstetricians to see much value in pediatric prenatal visits. They want us there in a flash when things go sour, but somehow they can't remember to encourage their patients to visit and choose a pediatrician in the calm of the second trimester.
The Cost of Continuity
“Welcome to the Bowdoin Medical Group, Mrs. Talbot. We're happy you've chosen to bring your children to see us. You look familiar. Have you been living here in Brunswick for a while?”
“Yes, we moved here about 6 years ago, but I got tired of never being sure which doctor my children would see when I took them to the XYZ Clinic. We've heard that will happen less frequently here with your group.”
Like “evidence-based,” “continuity” is one of those warm fuzzy concepts that we pediatricians have been told to clutch to our breasts and cuddle with when the cold winds of change are stinging our faces.
But, which evidence are we to believe and who among us has the stamina to volunteer to be available to our patients 24/7/365?
Continuity can create a sense of security that we all enjoy whether we are seeking reassurance about our health or merely picking up our dry cleaning.
I contend that the reason Mr. Peterson continued to return to Cheers was not because the beer was cold and plentiful, but because he was always greeted with a resounding welcome of “Norm!!” every time he walked through the door.
Familiarity breeds comfort, not contempt.
But when it comes to the delivery of medical care, familiarity and continuity also foster safety and efficiency.
When the same physician sees the patient, the history-taking part of the encounter takes far less time and documentation needs to be far less detailed.
Those fragments of social and family history that may hold the key to the patient's recurring abdominal pains surface more quickly for a familiar face but may never appear for the physician/stranger.
In a survey of surgery and internal medicine residents, one investigator discovered that after the Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions came into effect, the residents felt that continuity had decreased significantly and the quality of care had suffered slightly. It appears that errors attributable to physician fatigue may have been replaced with those related to discontinuous care.
One may argue that from time to time a patient may benefit from having his/her concerns considered by another physician with a different perspective.
However, when all is said and done, patients prefer being seen by the same physician and, in my view, receive better care when it is continuous.
But, continuity is costly. How many physicians have found themselves smoldering on the pyre of colleagues burned out in an attempt to be available to their patients 24/7/365?
Even the illusion of continuity created by well-crafted coverage arrangements can be expensive.
Documentation must be accurate and available to the surrogate provider when the patient is seen. Quality transcription and electronic medical records don't come cheap.
Dividing a larger group into smaller working units can provide the familiarity that patients want and need.
But, chopping a practice into bite-sized teams works only if everyone on the team buys into the concept that continuity is important.
In our group we feel that we do a pretty good job at having our patients see the same physician as often as possible.
However, we struggle with continuity at the front desk.
Our 8 a.m. to 7 p.m. (or later) office hours mean that receptionists change shifts once or twice each day. We would like our patients to be welcomed by a familiar face when they arrive. But, it just isn't happening.
I guess I shouldn't fret too much—we must be doing well enough to have earned a reputation that attracted Mrs. Talbot.
“Welcome to the Bowdoin Medical Group, Mrs. Talbot. We're happy you've chosen to bring your children to see us. You look familiar. Have you been living here in Brunswick for a while?”
“Yes, we moved here about 6 years ago, but I got tired of never being sure which doctor my children would see when I took them to the XYZ Clinic. We've heard that will happen less frequently here with your group.”
Like “evidence-based,” “continuity” is one of those warm fuzzy concepts that we pediatricians have been told to clutch to our breasts and cuddle with when the cold winds of change are stinging our faces.
But, which evidence are we to believe and who among us has the stamina to volunteer to be available to our patients 24/7/365?
Continuity can create a sense of security that we all enjoy whether we are seeking reassurance about our health or merely picking up our dry cleaning.
I contend that the reason Mr. Peterson continued to return to Cheers was not because the beer was cold and plentiful, but because he was always greeted with a resounding welcome of “Norm!!” every time he walked through the door.
Familiarity breeds comfort, not contempt.
But when it comes to the delivery of medical care, familiarity and continuity also foster safety and efficiency.
When the same physician sees the patient, the history-taking part of the encounter takes far less time and documentation needs to be far less detailed.
Those fragments of social and family history that may hold the key to the patient's recurring abdominal pains surface more quickly for a familiar face but may never appear for the physician/stranger.
In a survey of surgery and internal medicine residents, one investigator discovered that after the Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions came into effect, the residents felt that continuity had decreased significantly and the quality of care had suffered slightly. It appears that errors attributable to physician fatigue may have been replaced with those related to discontinuous care.
One may argue that from time to time a patient may benefit from having his/her concerns considered by another physician with a different perspective.
However, when all is said and done, patients prefer being seen by the same physician and, in my view, receive better care when it is continuous.
But, continuity is costly. How many physicians have found themselves smoldering on the pyre of colleagues burned out in an attempt to be available to their patients 24/7/365?
Even the illusion of continuity created by well-crafted coverage arrangements can be expensive.
Documentation must be accurate and available to the surrogate provider when the patient is seen. Quality transcription and electronic medical records don't come cheap.
Dividing a larger group into smaller working units can provide the familiarity that patients want and need.
But, chopping a practice into bite-sized teams works only if everyone on the team buys into the concept that continuity is important.
In our group we feel that we do a pretty good job at having our patients see the same physician as often as possible.
However, we struggle with continuity at the front desk.
Our 8 a.m. to 7 p.m. (or later) office hours mean that receptionists change shifts once or twice each day. We would like our patients to be welcomed by a familiar face when they arrive. But, it just isn't happening.
I guess I shouldn't fret too much—we must be doing well enough to have earned a reputation that attracted Mrs. Talbot.
“Welcome to the Bowdoin Medical Group, Mrs. Talbot. We're happy you've chosen to bring your children to see us. You look familiar. Have you been living here in Brunswick for a while?”
“Yes, we moved here about 6 years ago, but I got tired of never being sure which doctor my children would see when I took them to the XYZ Clinic. We've heard that will happen less frequently here with your group.”
Like “evidence-based,” “continuity” is one of those warm fuzzy concepts that we pediatricians have been told to clutch to our breasts and cuddle with when the cold winds of change are stinging our faces.
But, which evidence are we to believe and who among us has the stamina to volunteer to be available to our patients 24/7/365?
Continuity can create a sense of security that we all enjoy whether we are seeking reassurance about our health or merely picking up our dry cleaning.
I contend that the reason Mr. Peterson continued to return to Cheers was not because the beer was cold and plentiful, but because he was always greeted with a resounding welcome of “Norm!!” every time he walked through the door.
Familiarity breeds comfort, not contempt.
But when it comes to the delivery of medical care, familiarity and continuity also foster safety and efficiency.
When the same physician sees the patient, the history-taking part of the encounter takes far less time and documentation needs to be far less detailed.
Those fragments of social and family history that may hold the key to the patient's recurring abdominal pains surface more quickly for a familiar face but may never appear for the physician/stranger.
In a survey of surgery and internal medicine residents, one investigator discovered that after the Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions came into effect, the residents felt that continuity had decreased significantly and the quality of care had suffered slightly. It appears that errors attributable to physician fatigue may have been replaced with those related to discontinuous care.
One may argue that from time to time a patient may benefit from having his/her concerns considered by another physician with a different perspective.
However, when all is said and done, patients prefer being seen by the same physician and, in my view, receive better care when it is continuous.
But, continuity is costly. How many physicians have found themselves smoldering on the pyre of colleagues burned out in an attempt to be available to their patients 24/7/365?
Even the illusion of continuity created by well-crafted coverage arrangements can be expensive.
Documentation must be accurate and available to the surrogate provider when the patient is seen. Quality transcription and electronic medical records don't come cheap.
Dividing a larger group into smaller working units can provide the familiarity that patients want and need.
But, chopping a practice into bite-sized teams works only if everyone on the team buys into the concept that continuity is important.
In our group we feel that we do a pretty good job at having our patients see the same physician as often as possible.
However, we struggle with continuity at the front desk.
Our 8 a.m. to 7 p.m. (or later) office hours mean that receptionists change shifts once or twice each day. We would like our patients to be welcomed by a familiar face when they arrive. But, it just isn't happening.
I guess I shouldn't fret too much—we must be doing well enough to have earned a reputation that attracted Mrs. Talbot.
A Shot of Confidence
I've written about it several times, and we have all experienced it. The inevitable erosion of technical skills starts the month you leave your hospital-based, high-acuity residency programs and begin practicing outpatient primary care. You've been warned to “use it or lose it.” You may try to stay sharp by taking some hands-on refresher courses, but the opportunities to use your technical skills are fewer and fewer with each month of disuse.
And, with less opportunity to experience success, one's confidence begins to dip to dysfunctional levels. Tackling a procedure with a serious debt of confidence is one of the best ways to ensure failure.
A few weeks ago when I was in a particularly dark valley of technical self-doubt, I took a mini-inventory of my few remaining skills. Despite the fact that I can't remember whether I started an IV last year, I still have just a smidge of confidence that in an emergency I could use an old-fashioned butterfly needle. But, of course, their rigid design significantly shortens their life span. Surprisingly, I have just a shade more confidence of my ability to do lumbar punctures. However, these little glimmers of confidence are just that, very tiny sparkles of light on a dark landscape of technical skill.
But, there are a few shining examples that I can be trusted with sharp instruments. Although I have infrequent opportunities to stick needles into blood vessels and other vital structures of varying size and visibility, I do a mess of injections. And, while administering immunizations may not sound like the most challenging technical skill, nonetheless it is a skill … and at the risk of sounding pompous, I must say I'm pretty darn good at it.
It's not unusual for a parent to say, “He didn't even cry.” Or for a preteen to ask, “Did you do it? That didn't hurt.” From my admittedly biased and self-promoting perspective, when it comes to giving injections I feel I'm near the top of the heap.
Just do the math. In the course of an average day that includes six or eight health maintenance visits, I could be administering 25 or 30 immunizations. If I have been paying attention only half of the time, I must be learning something that can make the process more comfortable for my patients.
First of all, I'm fast and prepared. I have a little understanding with the nurses in our office. If the injection materials aren't drawn up and ready in the room when I'm ready to give the shot, they have to give the injection. I'm not sure whether this strategy qualifies as a carrot or a stick, but it works extremely well.
Next, I make sure the patient is in a situation where he or she will be well restrained. This requires an accurate assessment of the parent's mindset and ability to hold the child. Sometimes, despite my best coaching, some 150-pound adults can't seem to hold even one extremity of someone weighing only 25 pounds.
Although I do a ritualistic alcohol swipe, I don't and never have drawn back on the syringe before the injection. I have read that this maneuver increases the discomfort and doesn't minimize the risk of an untoward consequence. I try to distract the child by squeezing or gently pinching another portion of the target extremity. I give the most painful injection last, a strategy that has recently been shown to decrease the pain of the first vaccine (Pediatric News, “In Vaccine '1–2 Punch,' the Second Hurts More,” June 2007, p. 13).
But most importantly, I try to be as matter-of-fact as I can be about the whole shot process. Unfortunately, many children arrive at their well-child visit in a high state of anxiety fueled by well-meaning parents and not-so-well-intentioned older siblings and schoolmates. Promises of gifts and trips for ice cream may have further inflamed the situation to a point that even a confident master technician like myself is going to fail to give a painless injection. In the words of my old lacrosse coach, “All you can do is give it your best shot.”
I've written about it several times, and we have all experienced it. The inevitable erosion of technical skills starts the month you leave your hospital-based, high-acuity residency programs and begin practicing outpatient primary care. You've been warned to “use it or lose it.” You may try to stay sharp by taking some hands-on refresher courses, but the opportunities to use your technical skills are fewer and fewer with each month of disuse.
And, with less opportunity to experience success, one's confidence begins to dip to dysfunctional levels. Tackling a procedure with a serious debt of confidence is one of the best ways to ensure failure.
A few weeks ago when I was in a particularly dark valley of technical self-doubt, I took a mini-inventory of my few remaining skills. Despite the fact that I can't remember whether I started an IV last year, I still have just a smidge of confidence that in an emergency I could use an old-fashioned butterfly needle. But, of course, their rigid design significantly shortens their life span. Surprisingly, I have just a shade more confidence of my ability to do lumbar punctures. However, these little glimmers of confidence are just that, very tiny sparkles of light on a dark landscape of technical skill.
But, there are a few shining examples that I can be trusted with sharp instruments. Although I have infrequent opportunities to stick needles into blood vessels and other vital structures of varying size and visibility, I do a mess of injections. And, while administering immunizations may not sound like the most challenging technical skill, nonetheless it is a skill … and at the risk of sounding pompous, I must say I'm pretty darn good at it.
It's not unusual for a parent to say, “He didn't even cry.” Or for a preteen to ask, “Did you do it? That didn't hurt.” From my admittedly biased and self-promoting perspective, when it comes to giving injections I feel I'm near the top of the heap.
Just do the math. In the course of an average day that includes six or eight health maintenance visits, I could be administering 25 or 30 immunizations. If I have been paying attention only half of the time, I must be learning something that can make the process more comfortable for my patients.
First of all, I'm fast and prepared. I have a little understanding with the nurses in our office. If the injection materials aren't drawn up and ready in the room when I'm ready to give the shot, they have to give the injection. I'm not sure whether this strategy qualifies as a carrot or a stick, but it works extremely well.
Next, I make sure the patient is in a situation where he or she will be well restrained. This requires an accurate assessment of the parent's mindset and ability to hold the child. Sometimes, despite my best coaching, some 150-pound adults can't seem to hold even one extremity of someone weighing only 25 pounds.
Although I do a ritualistic alcohol swipe, I don't and never have drawn back on the syringe before the injection. I have read that this maneuver increases the discomfort and doesn't minimize the risk of an untoward consequence. I try to distract the child by squeezing or gently pinching another portion of the target extremity. I give the most painful injection last, a strategy that has recently been shown to decrease the pain of the first vaccine (Pediatric News, “In Vaccine '1–2 Punch,' the Second Hurts More,” June 2007, p. 13).
But most importantly, I try to be as matter-of-fact as I can be about the whole shot process. Unfortunately, many children arrive at their well-child visit in a high state of anxiety fueled by well-meaning parents and not-so-well-intentioned older siblings and schoolmates. Promises of gifts and trips for ice cream may have further inflamed the situation to a point that even a confident master technician like myself is going to fail to give a painless injection. In the words of my old lacrosse coach, “All you can do is give it your best shot.”
I've written about it several times, and we have all experienced it. The inevitable erosion of technical skills starts the month you leave your hospital-based, high-acuity residency programs and begin practicing outpatient primary care. You've been warned to “use it or lose it.” You may try to stay sharp by taking some hands-on refresher courses, but the opportunities to use your technical skills are fewer and fewer with each month of disuse.
And, with less opportunity to experience success, one's confidence begins to dip to dysfunctional levels. Tackling a procedure with a serious debt of confidence is one of the best ways to ensure failure.
A few weeks ago when I was in a particularly dark valley of technical self-doubt, I took a mini-inventory of my few remaining skills. Despite the fact that I can't remember whether I started an IV last year, I still have just a smidge of confidence that in an emergency I could use an old-fashioned butterfly needle. But, of course, their rigid design significantly shortens their life span. Surprisingly, I have just a shade more confidence of my ability to do lumbar punctures. However, these little glimmers of confidence are just that, very tiny sparkles of light on a dark landscape of technical skill.
But, there are a few shining examples that I can be trusted with sharp instruments. Although I have infrequent opportunities to stick needles into blood vessels and other vital structures of varying size and visibility, I do a mess of injections. And, while administering immunizations may not sound like the most challenging technical skill, nonetheless it is a skill … and at the risk of sounding pompous, I must say I'm pretty darn good at it.
It's not unusual for a parent to say, “He didn't even cry.” Or for a preteen to ask, “Did you do it? That didn't hurt.” From my admittedly biased and self-promoting perspective, when it comes to giving injections I feel I'm near the top of the heap.
Just do the math. In the course of an average day that includes six or eight health maintenance visits, I could be administering 25 or 30 immunizations. If I have been paying attention only half of the time, I must be learning something that can make the process more comfortable for my patients.
First of all, I'm fast and prepared. I have a little understanding with the nurses in our office. If the injection materials aren't drawn up and ready in the room when I'm ready to give the shot, they have to give the injection. I'm not sure whether this strategy qualifies as a carrot or a stick, but it works extremely well.
Next, I make sure the patient is in a situation where he or she will be well restrained. This requires an accurate assessment of the parent's mindset and ability to hold the child. Sometimes, despite my best coaching, some 150-pound adults can't seem to hold even one extremity of someone weighing only 25 pounds.
Although I do a ritualistic alcohol swipe, I don't and never have drawn back on the syringe before the injection. I have read that this maneuver increases the discomfort and doesn't minimize the risk of an untoward consequence. I try to distract the child by squeezing or gently pinching another portion of the target extremity. I give the most painful injection last, a strategy that has recently been shown to decrease the pain of the first vaccine (Pediatric News, “In Vaccine '1–2 Punch,' the Second Hurts More,” June 2007, p. 13).
But most importantly, I try to be as matter-of-fact as I can be about the whole shot process. Unfortunately, many children arrive at their well-child visit in a high state of anxiety fueled by well-meaning parents and not-so-well-intentioned older siblings and schoolmates. Promises of gifts and trips for ice cream may have further inflamed the situation to a point that even a confident master technician like myself is going to fail to give a painless injection. In the words of my old lacrosse coach, “All you can do is give it your best shot.”
The Right Stuff
One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”
In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.
Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.
There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.
For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.
The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.
It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.
So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.
The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.
One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”
In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.
Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.
There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.
For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.
The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.
It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.
So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.
The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.
One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”
In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.
Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.
There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.
For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.
The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.
It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.
So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.
The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.
Closure … Now or Later?
One of our newer physicians asked recently if I had any suggestions for increasing his efficiency. It's getting closer to the day his income will be based solely on productivity, and the handwriting on the wall is coming into clearer focus.
Never being bashful about pontificating, I began by suggesting that he move efficiency up his priority list to the same level as quality care and professional enjoyment. I continued by urging him to arrive early enough to make his call-backs and see his first patient on time. Playing catch-up isn't fun, and it certainly isn't efficient.
Then I said, “I've noticed that you do a lot of double-dipping.” His puzzled expression prompted me to explain that every time a physician leaves and returns to the examination room to see the same patient he must invest valuable time reestablishing the dialogue and the continuity of the visit. These return trips can be as costly as a full office visit, but of course the insurance companies don't reimburse for them.
A typical example involves a visit for a sore throat at which one does a rapid strep test. Before leaving the room with swab in hand, the efficient physician will have already discussed Plan A (test is positive) and Plan B (test is negative) with the patient and will have written a prescription for his choice of antibiotic so that his assistant can finish the visit. The experienced physician will have anticipated all of the usual questions and touched on them before exiting the room.
My student-for-the-moment said, “I can see what you mean, and I've been trying to get it all done with one trip into the exam room when I can. But, communication is important to me and I want to take advantage of every opportunity to achieve closure.”
Contorting my face into what I hoped was my wisest expression, I said, “Ah, closure—now there's a troubling concept.” Most training programs are in large metropolitan areas and serve outpatient populations that are often transient and economically disadvantaged. This fact, combined with the reality that house officers rotate and graduate, makes the establishment of a medical home model extremely difficult. I know that some programs work very hard to create continuity, but still most outpatient encounters exist in a vacuum. The physician-in-training and the patient understandably assume that they may never see or hear from each other again. In this dynamic, the physician's concern about achieving closure may squeeze common sense out of the picture.
Lab work is ordered to make sure that all the stones have been turned. Treatments of dubious value may be recommended and anxiety-provoking options are discussed unnecessarily because the practitioner is worried that he only has one chance to cover all his bases.
Many patients arrive at the physician's office in the early stages of an illness that is likely to be self-limited. Even the best diagnostician can't predict exactly where the process will go. Attempts at achieving closure in this fluid state are fruitless, time consuming, and potentially dangerous.
I urged my young associate to take full advantage of the fact that we live in a stable community of reasonably educated people. I suggested that he tell the patients that he is sure what they don't have, but that it is too early to be sure exactly what they do have or to expect the illness to have run its course.
I said, “Remind them that you and your partners are truly available by phone around the clock. Promise that you will call them the next day to see how things are going and then keep your promise. If you detect in your follow-up call even a hint of uncertainty, don't hesitate to have the patient return for another visit. That kind of double-dipping can teach you something, and you'll get paid to boot.”
As I rose to see my first patient of the afternoon 5 minutes late, I reminded my young associate that, “In a well-organized and compassionate outpatient setting, closure will come naturally. You won't have to waste time forcing it before it's ready to happen.”
One of our newer physicians asked recently if I had any suggestions for increasing his efficiency. It's getting closer to the day his income will be based solely on productivity, and the handwriting on the wall is coming into clearer focus.
Never being bashful about pontificating, I began by suggesting that he move efficiency up his priority list to the same level as quality care and professional enjoyment. I continued by urging him to arrive early enough to make his call-backs and see his first patient on time. Playing catch-up isn't fun, and it certainly isn't efficient.
Then I said, “I've noticed that you do a lot of double-dipping.” His puzzled expression prompted me to explain that every time a physician leaves and returns to the examination room to see the same patient he must invest valuable time reestablishing the dialogue and the continuity of the visit. These return trips can be as costly as a full office visit, but of course the insurance companies don't reimburse for them.
A typical example involves a visit for a sore throat at which one does a rapid strep test. Before leaving the room with swab in hand, the efficient physician will have already discussed Plan A (test is positive) and Plan B (test is negative) with the patient and will have written a prescription for his choice of antibiotic so that his assistant can finish the visit. The experienced physician will have anticipated all of the usual questions and touched on them before exiting the room.
My student-for-the-moment said, “I can see what you mean, and I've been trying to get it all done with one trip into the exam room when I can. But, communication is important to me and I want to take advantage of every opportunity to achieve closure.”
Contorting my face into what I hoped was my wisest expression, I said, “Ah, closure—now there's a troubling concept.” Most training programs are in large metropolitan areas and serve outpatient populations that are often transient and economically disadvantaged. This fact, combined with the reality that house officers rotate and graduate, makes the establishment of a medical home model extremely difficult. I know that some programs work very hard to create continuity, but still most outpatient encounters exist in a vacuum. The physician-in-training and the patient understandably assume that they may never see or hear from each other again. In this dynamic, the physician's concern about achieving closure may squeeze common sense out of the picture.
Lab work is ordered to make sure that all the stones have been turned. Treatments of dubious value may be recommended and anxiety-provoking options are discussed unnecessarily because the practitioner is worried that he only has one chance to cover all his bases.
Many patients arrive at the physician's office in the early stages of an illness that is likely to be self-limited. Even the best diagnostician can't predict exactly where the process will go. Attempts at achieving closure in this fluid state are fruitless, time consuming, and potentially dangerous.
I urged my young associate to take full advantage of the fact that we live in a stable community of reasonably educated people. I suggested that he tell the patients that he is sure what they don't have, but that it is too early to be sure exactly what they do have or to expect the illness to have run its course.
I said, “Remind them that you and your partners are truly available by phone around the clock. Promise that you will call them the next day to see how things are going and then keep your promise. If you detect in your follow-up call even a hint of uncertainty, don't hesitate to have the patient return for another visit. That kind of double-dipping can teach you something, and you'll get paid to boot.”
As I rose to see my first patient of the afternoon 5 minutes late, I reminded my young associate that, “In a well-organized and compassionate outpatient setting, closure will come naturally. You won't have to waste time forcing it before it's ready to happen.”
One of our newer physicians asked recently if I had any suggestions for increasing his efficiency. It's getting closer to the day his income will be based solely on productivity, and the handwriting on the wall is coming into clearer focus.
Never being bashful about pontificating, I began by suggesting that he move efficiency up his priority list to the same level as quality care and professional enjoyment. I continued by urging him to arrive early enough to make his call-backs and see his first patient on time. Playing catch-up isn't fun, and it certainly isn't efficient.
Then I said, “I've noticed that you do a lot of double-dipping.” His puzzled expression prompted me to explain that every time a physician leaves and returns to the examination room to see the same patient he must invest valuable time reestablishing the dialogue and the continuity of the visit. These return trips can be as costly as a full office visit, but of course the insurance companies don't reimburse for them.
A typical example involves a visit for a sore throat at which one does a rapid strep test. Before leaving the room with swab in hand, the efficient physician will have already discussed Plan A (test is positive) and Plan B (test is negative) with the patient and will have written a prescription for his choice of antibiotic so that his assistant can finish the visit. The experienced physician will have anticipated all of the usual questions and touched on them before exiting the room.
My student-for-the-moment said, “I can see what you mean, and I've been trying to get it all done with one trip into the exam room when I can. But, communication is important to me and I want to take advantage of every opportunity to achieve closure.”
Contorting my face into what I hoped was my wisest expression, I said, “Ah, closure—now there's a troubling concept.” Most training programs are in large metropolitan areas and serve outpatient populations that are often transient and economically disadvantaged. This fact, combined with the reality that house officers rotate and graduate, makes the establishment of a medical home model extremely difficult. I know that some programs work very hard to create continuity, but still most outpatient encounters exist in a vacuum. The physician-in-training and the patient understandably assume that they may never see or hear from each other again. In this dynamic, the physician's concern about achieving closure may squeeze common sense out of the picture.
Lab work is ordered to make sure that all the stones have been turned. Treatments of dubious value may be recommended and anxiety-provoking options are discussed unnecessarily because the practitioner is worried that he only has one chance to cover all his bases.
Many patients arrive at the physician's office in the early stages of an illness that is likely to be self-limited. Even the best diagnostician can't predict exactly where the process will go. Attempts at achieving closure in this fluid state are fruitless, time consuming, and potentially dangerous.
I urged my young associate to take full advantage of the fact that we live in a stable community of reasonably educated people. I suggested that he tell the patients that he is sure what they don't have, but that it is too early to be sure exactly what they do have or to expect the illness to have run its course.
I said, “Remind them that you and your partners are truly available by phone around the clock. Promise that you will call them the next day to see how things are going and then keep your promise. If you detect in your follow-up call even a hint of uncertainty, don't hesitate to have the patient return for another visit. That kind of double-dipping can teach you something, and you'll get paid to boot.”
As I rose to see my first patient of the afternoon 5 minutes late, I reminded my young associate that, “In a well-organized and compassionate outpatient setting, closure will come naturally. You won't have to waste time forcing it before it's ready to happen.”
The 'ADHD Adult' Dilemma
Back in the Dark Ages, before Al Gore invented the Internet, there were hyperactive children. The most troublesome were sedated with tranquilizers, but eventually a counterintuitive discovery resulted in a more humane and successful management with amphetamines.
“Hyperactivity” morphed into a family of “attention-deficit hyperactivity disorders” when it became apparent that there were children whose minds jumped from distraction to distraction while their bodies remained relatively stationary.
In the 1980s most of us told parents that their children's attention-deficit hyperactivity disorder symptoms would abate during puberty so that medication could be discontinued. Of course, this prediction proved to be wrong in many cases.
In fact, some physicians and mental health workers began labeling previously undiagnosed adults as having ADHD and treating them with stimulants.
Should we pediatricians interpret this growing population of amphetamine-popping “ADHD adults” as an embarrassing diagnostic oversight and gear ourselves for a massive class-action suit by an entire generation of distracted and impulsive 30- or 40-somethings?
Do “ADHD adults” exist, and are we to blame?
Let me tell you what I think. It is pretty obvious to almost everyone who has watched a child mature that the attention span of a 15-year-old is significantly longer than that of a 15-month-old.
This is true even for those children whose nervous systems' chemical and structural arrangement makes it more difficult to pay attention.
And, it shouldn't surprise us that someone who was diagnosed as having ADHD as a child might remain on the distractible side of the bell-shaped curve of adults.
But, if our management of ADHD has been more comprehensive than simply writing Ritalin prescriptions, most of our patients should not require medication by the time they leave our practices.
It is unreasonable to ask educators and parents to adapt every child's environment to match his/her individual personality and learning style.
In the case of ADHD, stimulant medication can ease that round peg-square hole fit while we adults are helping the children find topics, activities, environments, and vocations that will keep their interest long enough to allow them to experience success. We can hope that medication will buy us some time while we wait for the natural process of maturity to come to our rescue. But, hoping isn't enough.
The educational process should include thoughtful and creative planning of curricula and learning spaces. Vocational experiences such as job shadowing and social skills coaching should be considered. Of course, these observations apply to any child whose learning style and capabilities are out of the mainstream. And certainly it doesn't happen enough.
Now, what about the 40-year-old college graduate who shows up in the internist's office complaining that he is having trouble concentrating, that he needs three cups of coffee just to get through the first hour at work, and that he never feels fulfilled in anything he does because he is always jumping from one thing to another? He's already taken a 10-question test that he found in a magazine and discovered that he has all the symptoms of adult ADHD.
Well, he got through college with prescription stimulants, so I think you and I can figure we are off the hook for a missed diagnosis. We can only hope that his internist understands that distractibility and impulsiveness can be symptoms of sleep deprivation and depression as well as the result of family and social turmoil.
It may be that this unfortunate guy has simply found himself with the wrong job and/or the wrong spouse. It's very possible that some stimulants stronger than his three morning cups of coffee will make him feel better for a while, but I suspect in the long run things won't improve without a broader approach.
We pediatricians know that just because Ritalin seems to improve some of the symptoms, it doesn't mean that our young patient has ADHD. In my opinion, if you need Ritalin to do your job, you need a new job.
There may be a few adult patients with “true” ADHD today who have escaped detection, but I can't imagine that anyone in the next generation will reach the age of 30 without a day care provider, teacher, or well-meaning aunt suggesting, “You should ask the doctor if he has ADHD.”
Back in the Dark Ages, before Al Gore invented the Internet, there were hyperactive children. The most troublesome were sedated with tranquilizers, but eventually a counterintuitive discovery resulted in a more humane and successful management with amphetamines.
“Hyperactivity” morphed into a family of “attention-deficit hyperactivity disorders” when it became apparent that there were children whose minds jumped from distraction to distraction while their bodies remained relatively stationary.
In the 1980s most of us told parents that their children's attention-deficit hyperactivity disorder symptoms would abate during puberty so that medication could be discontinued. Of course, this prediction proved to be wrong in many cases.
In fact, some physicians and mental health workers began labeling previously undiagnosed adults as having ADHD and treating them with stimulants.
Should we pediatricians interpret this growing population of amphetamine-popping “ADHD adults” as an embarrassing diagnostic oversight and gear ourselves for a massive class-action suit by an entire generation of distracted and impulsive 30- or 40-somethings?
Do “ADHD adults” exist, and are we to blame?
Let me tell you what I think. It is pretty obvious to almost everyone who has watched a child mature that the attention span of a 15-year-old is significantly longer than that of a 15-month-old.
This is true even for those children whose nervous systems' chemical and structural arrangement makes it more difficult to pay attention.
And, it shouldn't surprise us that someone who was diagnosed as having ADHD as a child might remain on the distractible side of the bell-shaped curve of adults.
But, if our management of ADHD has been more comprehensive than simply writing Ritalin prescriptions, most of our patients should not require medication by the time they leave our practices.
It is unreasonable to ask educators and parents to adapt every child's environment to match his/her individual personality and learning style.
In the case of ADHD, stimulant medication can ease that round peg-square hole fit while we adults are helping the children find topics, activities, environments, and vocations that will keep their interest long enough to allow them to experience success. We can hope that medication will buy us some time while we wait for the natural process of maturity to come to our rescue. But, hoping isn't enough.
The educational process should include thoughtful and creative planning of curricula and learning spaces. Vocational experiences such as job shadowing and social skills coaching should be considered. Of course, these observations apply to any child whose learning style and capabilities are out of the mainstream. And certainly it doesn't happen enough.
Now, what about the 40-year-old college graduate who shows up in the internist's office complaining that he is having trouble concentrating, that he needs three cups of coffee just to get through the first hour at work, and that he never feels fulfilled in anything he does because he is always jumping from one thing to another? He's already taken a 10-question test that he found in a magazine and discovered that he has all the symptoms of adult ADHD.
Well, he got through college with prescription stimulants, so I think you and I can figure we are off the hook for a missed diagnosis. We can only hope that his internist understands that distractibility and impulsiveness can be symptoms of sleep deprivation and depression as well as the result of family and social turmoil.
It may be that this unfortunate guy has simply found himself with the wrong job and/or the wrong spouse. It's very possible that some stimulants stronger than his three morning cups of coffee will make him feel better for a while, but I suspect in the long run things won't improve without a broader approach.
We pediatricians know that just because Ritalin seems to improve some of the symptoms, it doesn't mean that our young patient has ADHD. In my opinion, if you need Ritalin to do your job, you need a new job.
There may be a few adult patients with “true” ADHD today who have escaped detection, but I can't imagine that anyone in the next generation will reach the age of 30 without a day care provider, teacher, or well-meaning aunt suggesting, “You should ask the doctor if he has ADHD.”
Back in the Dark Ages, before Al Gore invented the Internet, there were hyperactive children. The most troublesome were sedated with tranquilizers, but eventually a counterintuitive discovery resulted in a more humane and successful management with amphetamines.
“Hyperactivity” morphed into a family of “attention-deficit hyperactivity disorders” when it became apparent that there were children whose minds jumped from distraction to distraction while their bodies remained relatively stationary.
In the 1980s most of us told parents that their children's attention-deficit hyperactivity disorder symptoms would abate during puberty so that medication could be discontinued. Of course, this prediction proved to be wrong in many cases.
In fact, some physicians and mental health workers began labeling previously undiagnosed adults as having ADHD and treating them with stimulants.
Should we pediatricians interpret this growing population of amphetamine-popping “ADHD adults” as an embarrassing diagnostic oversight and gear ourselves for a massive class-action suit by an entire generation of distracted and impulsive 30- or 40-somethings?
Do “ADHD adults” exist, and are we to blame?
Let me tell you what I think. It is pretty obvious to almost everyone who has watched a child mature that the attention span of a 15-year-old is significantly longer than that of a 15-month-old.
This is true even for those children whose nervous systems' chemical and structural arrangement makes it more difficult to pay attention.
And, it shouldn't surprise us that someone who was diagnosed as having ADHD as a child might remain on the distractible side of the bell-shaped curve of adults.
But, if our management of ADHD has been more comprehensive than simply writing Ritalin prescriptions, most of our patients should not require medication by the time they leave our practices.
It is unreasonable to ask educators and parents to adapt every child's environment to match his/her individual personality and learning style.
In the case of ADHD, stimulant medication can ease that round peg-square hole fit while we adults are helping the children find topics, activities, environments, and vocations that will keep their interest long enough to allow them to experience success. We can hope that medication will buy us some time while we wait for the natural process of maturity to come to our rescue. But, hoping isn't enough.
The educational process should include thoughtful and creative planning of curricula and learning spaces. Vocational experiences such as job shadowing and social skills coaching should be considered. Of course, these observations apply to any child whose learning style and capabilities are out of the mainstream. And certainly it doesn't happen enough.
Now, what about the 40-year-old college graduate who shows up in the internist's office complaining that he is having trouble concentrating, that he needs three cups of coffee just to get through the first hour at work, and that he never feels fulfilled in anything he does because he is always jumping from one thing to another? He's already taken a 10-question test that he found in a magazine and discovered that he has all the symptoms of adult ADHD.
Well, he got through college with prescription stimulants, so I think you and I can figure we are off the hook for a missed diagnosis. We can only hope that his internist understands that distractibility and impulsiveness can be symptoms of sleep deprivation and depression as well as the result of family and social turmoil.
It may be that this unfortunate guy has simply found himself with the wrong job and/or the wrong spouse. It's very possible that some stimulants stronger than his three morning cups of coffee will make him feel better for a while, but I suspect in the long run things won't improve without a broader approach.
We pediatricians know that just because Ritalin seems to improve some of the symptoms, it doesn't mean that our young patient has ADHD. In my opinion, if you need Ritalin to do your job, you need a new job.
There may be a few adult patients with “true” ADHD today who have escaped detection, but I can't imagine that anyone in the next generation will reach the age of 30 without a day care provider, teacher, or well-meaning aunt suggesting, “You should ask the doctor if he has ADHD.”
Worst-Case Scenarios
One of my partners has a bit of an issue with anxiety. She claims this is a congenital thing and isn't the least bit timid about owning up to her nervousness. As you might expect, she is quite clever at imagining worst-case scenarios, which is a handy skill to have when it comes to crafting a list of differential diagnoses.
But Deb's bigger problem is that she somehow manages to attract a larger number of worst-case scenarios than one would expect based strictly on chance. This unfortunate magnetism has earned her the title of “Disaster Deb,” a moniker she wears with considerable pride.
So you can imagine that when the call came for someone to head up our local pandemic preparedness posse, Disaster Deb was the logical choice … and not surprisingly, the only volunteer. Now she could spend what little free time she has worrying about worst- case scenarios on a level that makes toddlers with fevers and necks that “might be stiff” seem like child's play.
Now she could hang out and hobnob with people who get paid to worry on a national and even a global scale. My only concern about Deb accepting this position was that she might do some additional worrying—that she was having too much fun exploring worst-case scenarios.
But, she has managed to keep her anxiety within bounds—well, at least normal bounds for her—and has done a bang-up job of spreading the doom and gloom about pandemics. She has helped the hospital and our medical group begin thinking about what we might have to do to manage an outbreak of severe influenza. She gives excellent presentations of the Center for Disease Control and Prevention's version of what a pandemic could look like. At the end of her talk she always serves some of her home-baked cookies in a tasty but unsuccessful attempt at calming the nerves of audience members whom she has sent into a palm-sweating panic.
I'm pretty immune to the scary bits in her presentations because I find the likelihood of an influenza pandemic extremely remote. I just eat the cookies and worry that this whole pandemic preparedness extravaganza is a poor investment of our public health resources.
Deb tries to reassure me that the mental exercises she is leading us through now will carry over and help us in future pandemics and other disasters. But I'm sure that when this pandemic fails to materialize, most of those who have listened attentively will turn a deaf ear to subsequent warnings when the real disaster comes. Our society has a very short memory when it comes to near disasters. When the oil prices go up we tilt at a few windmills and buy a handful of hybrid cars, but within a month or two we're back to driving our SUVs at breakneck speeds.
I find the pandemic preparedness plans are drawn too narrowly. The real disasters are by definition unpredictable and hence one can't prepare for them. When the dome of seismic instability under Yellowstone Park finally erupts and darkens the skies for months (an event that might be as likely as an avian flu pandemic), the reams of paper generated by our flu preparations may be useful as a temporary fuel source, but that's about it.
When the doodoo really hits the fan, our survivability is going to depend on the strength of the moral fiber that binds us together as a society and on the intelligence, creativity, and charisma of the leaders we have chosen. So you can see why from time to time I join Disaster Deb in some serious recreational worrying.
One of my partners has a bit of an issue with anxiety. She claims this is a congenital thing and isn't the least bit timid about owning up to her nervousness. As you might expect, she is quite clever at imagining worst-case scenarios, which is a handy skill to have when it comes to crafting a list of differential diagnoses.
But Deb's bigger problem is that she somehow manages to attract a larger number of worst-case scenarios than one would expect based strictly on chance. This unfortunate magnetism has earned her the title of “Disaster Deb,” a moniker she wears with considerable pride.
So you can imagine that when the call came for someone to head up our local pandemic preparedness posse, Disaster Deb was the logical choice … and not surprisingly, the only volunteer. Now she could spend what little free time she has worrying about worst- case scenarios on a level that makes toddlers with fevers and necks that “might be stiff” seem like child's play.
Now she could hang out and hobnob with people who get paid to worry on a national and even a global scale. My only concern about Deb accepting this position was that she might do some additional worrying—that she was having too much fun exploring worst-case scenarios.
But, she has managed to keep her anxiety within bounds—well, at least normal bounds for her—and has done a bang-up job of spreading the doom and gloom about pandemics. She has helped the hospital and our medical group begin thinking about what we might have to do to manage an outbreak of severe influenza. She gives excellent presentations of the Center for Disease Control and Prevention's version of what a pandemic could look like. At the end of her talk she always serves some of her home-baked cookies in a tasty but unsuccessful attempt at calming the nerves of audience members whom she has sent into a palm-sweating panic.
I'm pretty immune to the scary bits in her presentations because I find the likelihood of an influenza pandemic extremely remote. I just eat the cookies and worry that this whole pandemic preparedness extravaganza is a poor investment of our public health resources.
Deb tries to reassure me that the mental exercises she is leading us through now will carry over and help us in future pandemics and other disasters. But I'm sure that when this pandemic fails to materialize, most of those who have listened attentively will turn a deaf ear to subsequent warnings when the real disaster comes. Our society has a very short memory when it comes to near disasters. When the oil prices go up we tilt at a few windmills and buy a handful of hybrid cars, but within a month or two we're back to driving our SUVs at breakneck speeds.
I find the pandemic preparedness plans are drawn too narrowly. The real disasters are by definition unpredictable and hence one can't prepare for them. When the dome of seismic instability under Yellowstone Park finally erupts and darkens the skies for months (an event that might be as likely as an avian flu pandemic), the reams of paper generated by our flu preparations may be useful as a temporary fuel source, but that's about it.
When the doodoo really hits the fan, our survivability is going to depend on the strength of the moral fiber that binds us together as a society and on the intelligence, creativity, and charisma of the leaders we have chosen. So you can see why from time to time I join Disaster Deb in some serious recreational worrying.
One of my partners has a bit of an issue with anxiety. She claims this is a congenital thing and isn't the least bit timid about owning up to her nervousness. As you might expect, she is quite clever at imagining worst-case scenarios, which is a handy skill to have when it comes to crafting a list of differential diagnoses.
But Deb's bigger problem is that she somehow manages to attract a larger number of worst-case scenarios than one would expect based strictly on chance. This unfortunate magnetism has earned her the title of “Disaster Deb,” a moniker she wears with considerable pride.
So you can imagine that when the call came for someone to head up our local pandemic preparedness posse, Disaster Deb was the logical choice … and not surprisingly, the only volunteer. Now she could spend what little free time she has worrying about worst- case scenarios on a level that makes toddlers with fevers and necks that “might be stiff” seem like child's play.
Now she could hang out and hobnob with people who get paid to worry on a national and even a global scale. My only concern about Deb accepting this position was that she might do some additional worrying—that she was having too much fun exploring worst-case scenarios.
But, she has managed to keep her anxiety within bounds—well, at least normal bounds for her—and has done a bang-up job of spreading the doom and gloom about pandemics. She has helped the hospital and our medical group begin thinking about what we might have to do to manage an outbreak of severe influenza. She gives excellent presentations of the Center for Disease Control and Prevention's version of what a pandemic could look like. At the end of her talk she always serves some of her home-baked cookies in a tasty but unsuccessful attempt at calming the nerves of audience members whom she has sent into a palm-sweating panic.
I'm pretty immune to the scary bits in her presentations because I find the likelihood of an influenza pandemic extremely remote. I just eat the cookies and worry that this whole pandemic preparedness extravaganza is a poor investment of our public health resources.
Deb tries to reassure me that the mental exercises she is leading us through now will carry over and help us in future pandemics and other disasters. But I'm sure that when this pandemic fails to materialize, most of those who have listened attentively will turn a deaf ear to subsequent warnings when the real disaster comes. Our society has a very short memory when it comes to near disasters. When the oil prices go up we tilt at a few windmills and buy a handful of hybrid cars, but within a month or two we're back to driving our SUVs at breakneck speeds.
I find the pandemic preparedness plans are drawn too narrowly. The real disasters are by definition unpredictable and hence one can't prepare for them. When the dome of seismic instability under Yellowstone Park finally erupts and darkens the skies for months (an event that might be as likely as an avian flu pandemic), the reams of paper generated by our flu preparations may be useful as a temporary fuel source, but that's about it.
When the doodoo really hits the fan, our survivability is going to depend on the strength of the moral fiber that binds us together as a society and on the intelligence, creativity, and charisma of the leaders we have chosen. So you can see why from time to time I join Disaster Deb in some serious recreational worrying.
In Short Supply
“Sure, we can see your patient. How about 2 o'clock tomorrow? But if you think he needs to be seen sooner, send him right over and we can squeeze him in.” Those are words that can make any harassed and worried primary care pediatrician feel all warm and fuzzy inside.
Even if you are pretty sure the patient is healthy, it's a great relief when someone else agrees to share the burden of an overanxious parent. Unfortunately, none of us has the luxury of working above a completely impermeable safety net of willing and accessible subspecialists. A lot has been written and said about the “open access” practice model for primary care physicians. In theory, it makes sense, and with some simple modifications it has worked well in our office for more than a decade.
But for a variety of good and bad reasons, the easy-open-door policy doesn't seem to work well for most subspecialists. I can see why the depth and complexity of the problems they see may dictate that their initial office visits be time-consuming. Nonetheless, there are a few saintly and busy subspecializing physicians who are so well organized and/or compassionate that their receptionists can offer timely rescue service to my patients.
I'm not sure how they do this, but I suspect that they do what I do when I feel swamped: I temporarily suspend my usual practice of doing a complete exam and history on every new patient. I try to ferret out the patient's primary problem and his parents' overriding concern and begin the process of getting to the bottom of it. I reassure the family that when we have time I will address all of their concerns, but I tell them that to squeeze them in today I will have to temporarily narrow my focus. Most families are so happy to be seen promptly that they are more than happy to accept my triage approach.
When I stumble across busy but easy-access subspecialists, I try to treat them as I would fine wines. I call on them only for special occasions and send them concise and focused histories. They also receive thank-you notes and some of Marilyn's baked goods at Christmas.
But despite our careful husbandry, my partners and I still must live with critical shortages in some subspecialty areas. If you share our pain and frustration, I urge you to read Dr. Daniel Goodman's commentary, “The Pediatric Subspecialty Workforce: Time to Test Our Assumptions,” in the December 2006 issue of Pediatrics.
Dr. Goodman doesn't claim to offer any solutions. But he poses a collection of thought-provoking questions, the answers to which may lead us out of the woods. For example, he wonders if fellowships need to take 3 years or sometimes longer. Is a niche always so deep that a subspecialist in training must invest what could be productive time exploring every abstruse nook and cranny?
Could providers with a modest amount of training learn to care for the bulk of a subspecialty's patients? Unusual and complex patients could be bumped up the ladder to a few master subspecialists.
In selected subspecialties, why can't physicians who were originally trained to see adults broaden their practices to include children? I don't think we have to worry that this change would herald the demise of general pediatrics.
If we read Dr. Goodman's commentary with an open mind and join him in thinking outside the box, we may have some solutions to the subspecialist shortages. Until then, I'm going to continue writing effusive thank-you notes and encourage Marilyn to keep baking her scrumptious cookies.
“Sure, we can see your patient. How about 2 o'clock tomorrow? But if you think he needs to be seen sooner, send him right over and we can squeeze him in.” Those are words that can make any harassed and worried primary care pediatrician feel all warm and fuzzy inside.
Even if you are pretty sure the patient is healthy, it's a great relief when someone else agrees to share the burden of an overanxious parent. Unfortunately, none of us has the luxury of working above a completely impermeable safety net of willing and accessible subspecialists. A lot has been written and said about the “open access” practice model for primary care physicians. In theory, it makes sense, and with some simple modifications it has worked well in our office for more than a decade.
But for a variety of good and bad reasons, the easy-open-door policy doesn't seem to work well for most subspecialists. I can see why the depth and complexity of the problems they see may dictate that their initial office visits be time-consuming. Nonetheless, there are a few saintly and busy subspecializing physicians who are so well organized and/or compassionate that their receptionists can offer timely rescue service to my patients.
I'm not sure how they do this, but I suspect that they do what I do when I feel swamped: I temporarily suspend my usual practice of doing a complete exam and history on every new patient. I try to ferret out the patient's primary problem and his parents' overriding concern and begin the process of getting to the bottom of it. I reassure the family that when we have time I will address all of their concerns, but I tell them that to squeeze them in today I will have to temporarily narrow my focus. Most families are so happy to be seen promptly that they are more than happy to accept my triage approach.
When I stumble across busy but easy-access subspecialists, I try to treat them as I would fine wines. I call on them only for special occasions and send them concise and focused histories. They also receive thank-you notes and some of Marilyn's baked goods at Christmas.
But despite our careful husbandry, my partners and I still must live with critical shortages in some subspecialty areas. If you share our pain and frustration, I urge you to read Dr. Daniel Goodman's commentary, “The Pediatric Subspecialty Workforce: Time to Test Our Assumptions,” in the December 2006 issue of Pediatrics.
Dr. Goodman doesn't claim to offer any solutions. But he poses a collection of thought-provoking questions, the answers to which may lead us out of the woods. For example, he wonders if fellowships need to take 3 years or sometimes longer. Is a niche always so deep that a subspecialist in training must invest what could be productive time exploring every abstruse nook and cranny?
Could providers with a modest amount of training learn to care for the bulk of a subspecialty's patients? Unusual and complex patients could be bumped up the ladder to a few master subspecialists.
In selected subspecialties, why can't physicians who were originally trained to see adults broaden their practices to include children? I don't think we have to worry that this change would herald the demise of general pediatrics.
If we read Dr. Goodman's commentary with an open mind and join him in thinking outside the box, we may have some solutions to the subspecialist shortages. Until then, I'm going to continue writing effusive thank-you notes and encourage Marilyn to keep baking her scrumptious cookies.
“Sure, we can see your patient. How about 2 o'clock tomorrow? But if you think he needs to be seen sooner, send him right over and we can squeeze him in.” Those are words that can make any harassed and worried primary care pediatrician feel all warm and fuzzy inside.
Even if you are pretty sure the patient is healthy, it's a great relief when someone else agrees to share the burden of an overanxious parent. Unfortunately, none of us has the luxury of working above a completely impermeable safety net of willing and accessible subspecialists. A lot has been written and said about the “open access” practice model for primary care physicians. In theory, it makes sense, and with some simple modifications it has worked well in our office for more than a decade.
But for a variety of good and bad reasons, the easy-open-door policy doesn't seem to work well for most subspecialists. I can see why the depth and complexity of the problems they see may dictate that their initial office visits be time-consuming. Nonetheless, there are a few saintly and busy subspecializing physicians who are so well organized and/or compassionate that their receptionists can offer timely rescue service to my patients.
I'm not sure how they do this, but I suspect that they do what I do when I feel swamped: I temporarily suspend my usual practice of doing a complete exam and history on every new patient. I try to ferret out the patient's primary problem and his parents' overriding concern and begin the process of getting to the bottom of it. I reassure the family that when we have time I will address all of their concerns, but I tell them that to squeeze them in today I will have to temporarily narrow my focus. Most families are so happy to be seen promptly that they are more than happy to accept my triage approach.
When I stumble across busy but easy-access subspecialists, I try to treat them as I would fine wines. I call on them only for special occasions and send them concise and focused histories. They also receive thank-you notes and some of Marilyn's baked goods at Christmas.
But despite our careful husbandry, my partners and I still must live with critical shortages in some subspecialty areas. If you share our pain and frustration, I urge you to read Dr. Daniel Goodman's commentary, “The Pediatric Subspecialty Workforce: Time to Test Our Assumptions,” in the December 2006 issue of Pediatrics.
Dr. Goodman doesn't claim to offer any solutions. But he poses a collection of thought-provoking questions, the answers to which may lead us out of the woods. For example, he wonders if fellowships need to take 3 years or sometimes longer. Is a niche always so deep that a subspecialist in training must invest what could be productive time exploring every abstruse nook and cranny?
Could providers with a modest amount of training learn to care for the bulk of a subspecialty's patients? Unusual and complex patients could be bumped up the ladder to a few master subspecialists.
In selected subspecialties, why can't physicians who were originally trained to see adults broaden their practices to include children? I don't think we have to worry that this change would herald the demise of general pediatrics.
If we read Dr. Goodman's commentary with an open mind and join him in thinking outside the box, we may have some solutions to the subspecialist shortages. Until then, I'm going to continue writing effusive thank-you notes and encourage Marilyn to keep baking her scrumptious cookies.
Battle Tested—and Better for It
The good news is that the flow of sick patients into the office has begun to slow. The viral gastroenteritis and the influenza-like illnesses that have plagued our community seem to be abating. We are now back to a more comfortable mix of slow-gaining breast-feeders, runnynosed toddlers, and limping teenaged athletes.
Physicians and staff are getting home in time to tuck their own children in for the night and sometimes even arriving before dinner is served. There are empty seats in the waiting room from time to time, and I no longer feel that I must begin each visit with an apology for running behind.
The rest of the good news is that weathering this 8-week siege of illness has forced everyone in the office to improve their efficiency so that now we are purring along like a well-oiled machine. Exam rooms are well supplied with otoscope pieces, tongue depressors, and ear curettes when the day begins because the nurses realize that once the patients start arriving, the window of opportunity to restock the drawers may not open again.
All the patients with vomiting or diarrhea are weighed before they see the physician. Children with urine complaints have already been coaxed into peeing and the results of their urinalyses are already on the chart before they are readied for an exam, and those with headaches or head bumps have had their blood pressures taken. The nurses who float over from the internist's pod from time to time are no longer wasting their time and irritating the patients by taking “routine” and meaningless temperatures.
The receptionists are asking more and better questions before they make appointments. After seeing a big influx of sicker-than-usual patients, they have witnessed multiple examples that support our office philosophy: Seeing the sicker patients early in the day helps things run more smoothly. Children with injuries that might require an x-ray are scheduled to come in when our in-house x-ray is staffed. Nearly all of the phone messages that arrive on the counter above the chart rack include sufficient information for the physician to give the correct advice without having to ask time-consuming follow-up questions.
The physicians are arriving in time to make their callbacks and are ready to sit down for our scheduled and promised call-in times. For some, this punctuality is a new habit spawned by the realization that when double-booking is the norm, there is no time to compensate for a late arrival.
The bad news is that 30 years of watching the ebb and flow of patient volume has taught me that after a few weeks of relative quiet, some old habits and inefficiencies will creep back into the routine. It's only natural. No one enjoys churning away at top speed, seeing patients in less time than they deserve.
For some staff members, this double-barreled outbreak was their first opportunity to see how busy a pediatric office can get. Of course, it also gave some of us old-timers the chance to tell a few “If you think this is busy …” stories. And I have grown to enjoy answering those, “Did you really see 85 patients in one day?” questions.
But there is even more good news. None of our permanent employees quit during the siege, and I think that most of our new employees now understand how some of our apparently trivial office policies came to be. When things are relatively quiet, it may not seem terribly important that each exam room always has an extra roll of paper towel under the sink. However, when a physician who is running 40 minutes behind finds herself out in the hall with wet hands instead of beginning her exam of a fussy and feverish 3-month-old, it isn't a pretty picture.
Office pediatrics will always be an unpredictable mix of chaos and calm. No one can write a practice manual that will make every day a stroll in the park. But, a well-run office can create commonsense policies that may help preserve the lessons that were so painfully learned in the heat of battle.
The good news is that the flow of sick patients into the office has begun to slow. The viral gastroenteritis and the influenza-like illnesses that have plagued our community seem to be abating. We are now back to a more comfortable mix of slow-gaining breast-feeders, runnynosed toddlers, and limping teenaged athletes.
Physicians and staff are getting home in time to tuck their own children in for the night and sometimes even arriving before dinner is served. There are empty seats in the waiting room from time to time, and I no longer feel that I must begin each visit with an apology for running behind.
The rest of the good news is that weathering this 8-week siege of illness has forced everyone in the office to improve their efficiency so that now we are purring along like a well-oiled machine. Exam rooms are well supplied with otoscope pieces, tongue depressors, and ear curettes when the day begins because the nurses realize that once the patients start arriving, the window of opportunity to restock the drawers may not open again.
All the patients with vomiting or diarrhea are weighed before they see the physician. Children with urine complaints have already been coaxed into peeing and the results of their urinalyses are already on the chart before they are readied for an exam, and those with headaches or head bumps have had their blood pressures taken. The nurses who float over from the internist's pod from time to time are no longer wasting their time and irritating the patients by taking “routine” and meaningless temperatures.
The receptionists are asking more and better questions before they make appointments. After seeing a big influx of sicker-than-usual patients, they have witnessed multiple examples that support our office philosophy: Seeing the sicker patients early in the day helps things run more smoothly. Children with injuries that might require an x-ray are scheduled to come in when our in-house x-ray is staffed. Nearly all of the phone messages that arrive on the counter above the chart rack include sufficient information for the physician to give the correct advice without having to ask time-consuming follow-up questions.
The physicians are arriving in time to make their callbacks and are ready to sit down for our scheduled and promised call-in times. For some, this punctuality is a new habit spawned by the realization that when double-booking is the norm, there is no time to compensate for a late arrival.
The bad news is that 30 years of watching the ebb and flow of patient volume has taught me that after a few weeks of relative quiet, some old habits and inefficiencies will creep back into the routine. It's only natural. No one enjoys churning away at top speed, seeing patients in less time than they deserve.
For some staff members, this double-barreled outbreak was their first opportunity to see how busy a pediatric office can get. Of course, it also gave some of us old-timers the chance to tell a few “If you think this is busy …” stories. And I have grown to enjoy answering those, “Did you really see 85 patients in one day?” questions.
But there is even more good news. None of our permanent employees quit during the siege, and I think that most of our new employees now understand how some of our apparently trivial office policies came to be. When things are relatively quiet, it may not seem terribly important that each exam room always has an extra roll of paper towel under the sink. However, when a physician who is running 40 minutes behind finds herself out in the hall with wet hands instead of beginning her exam of a fussy and feverish 3-month-old, it isn't a pretty picture.
Office pediatrics will always be an unpredictable mix of chaos and calm. No one can write a practice manual that will make every day a stroll in the park. But, a well-run office can create commonsense policies that may help preserve the lessons that were so painfully learned in the heat of battle.
The good news is that the flow of sick patients into the office has begun to slow. The viral gastroenteritis and the influenza-like illnesses that have plagued our community seem to be abating. We are now back to a more comfortable mix of slow-gaining breast-feeders, runnynosed toddlers, and limping teenaged athletes.
Physicians and staff are getting home in time to tuck their own children in for the night and sometimes even arriving before dinner is served. There are empty seats in the waiting room from time to time, and I no longer feel that I must begin each visit with an apology for running behind.
The rest of the good news is that weathering this 8-week siege of illness has forced everyone in the office to improve their efficiency so that now we are purring along like a well-oiled machine. Exam rooms are well supplied with otoscope pieces, tongue depressors, and ear curettes when the day begins because the nurses realize that once the patients start arriving, the window of opportunity to restock the drawers may not open again.
All the patients with vomiting or diarrhea are weighed before they see the physician. Children with urine complaints have already been coaxed into peeing and the results of their urinalyses are already on the chart before they are readied for an exam, and those with headaches or head bumps have had their blood pressures taken. The nurses who float over from the internist's pod from time to time are no longer wasting their time and irritating the patients by taking “routine” and meaningless temperatures.
The receptionists are asking more and better questions before they make appointments. After seeing a big influx of sicker-than-usual patients, they have witnessed multiple examples that support our office philosophy: Seeing the sicker patients early in the day helps things run more smoothly. Children with injuries that might require an x-ray are scheduled to come in when our in-house x-ray is staffed. Nearly all of the phone messages that arrive on the counter above the chart rack include sufficient information for the physician to give the correct advice without having to ask time-consuming follow-up questions.
The physicians are arriving in time to make their callbacks and are ready to sit down for our scheduled and promised call-in times. For some, this punctuality is a new habit spawned by the realization that when double-booking is the norm, there is no time to compensate for a late arrival.
The bad news is that 30 years of watching the ebb and flow of patient volume has taught me that after a few weeks of relative quiet, some old habits and inefficiencies will creep back into the routine. It's only natural. No one enjoys churning away at top speed, seeing patients in less time than they deserve.
For some staff members, this double-barreled outbreak was their first opportunity to see how busy a pediatric office can get. Of course, it also gave some of us old-timers the chance to tell a few “If you think this is busy …” stories. And I have grown to enjoy answering those, “Did you really see 85 patients in one day?” questions.
But there is even more good news. None of our permanent employees quit during the siege, and I think that most of our new employees now understand how some of our apparently trivial office policies came to be. When things are relatively quiet, it may not seem terribly important that each exam room always has an extra roll of paper towel under the sink. However, when a physician who is running 40 minutes behind finds herself out in the hall with wet hands instead of beginning her exam of a fussy and feverish 3-month-old, it isn't a pretty picture.
Office pediatrics will always be an unpredictable mix of chaos and calm. No one can write a practice manual that will make every day a stroll in the park. But, a well-run office can create commonsense policies that may help preserve the lessons that were so painfully learned in the heat of battle.