The Smart Parent's Guide Getting Your Kids Through Checkups, Illnesses, and Accidents
By Jennifer Trachtenberg
Free Press Copyright © 2010 Jennifer Trachtenberg
All right reserved. ISBN: 9781439152911
As a pediatrician, I am the best buddy and confidante for the parents of my patients. Want to know one of the most common confessions I hear from parents? They?re scared. Sometimes terrified. From caring for a teeny-tiny newborn to coping with a child?s medical crisis, they?re afraid they?ll make a horrible mistake. Good parents like you want to do everything right for their kids.
But a little bit of fear is a good thing. It keeps you on your toes?it makes you question, focus, and think. When it comes to your kids? health, being blissfully unaware can have devastating consequences. As a pediatrician and a mom of three, I?ve seen the good, the bad, and the very ugly on both sides of the stethoscope. I know the goofs that even ultra-intelligent parents can make and the mistakes that happen in even the best hospitals. Modern medicine can work wonders, but it can also do real harm, thanks to human errors and mechanical breakdowns.
That said, the last thing I want is to paralyze you with fear and worry. A much smarter strategy?one that I use myself and encourage you to use as well?is to use fear to your advantage. Treat being scared as a signal that you need to know more. The more you know, the smarter the decisions you?ll make about your children?s health. Yes, you?re right, there?s so much information out there that a person could drown in it. So what?s the best way to navigate this vast sea of new medical knowledge you?re blessed (and burdened) with?
1 in 15 children in hospitals is injured by medical mistakes and adverse drug reactions.
That?s why I wrote this book: to give you my insider?s recommendations on how to protect your child?s health. Because that?s your most important mission as a parent.
Don?t feel compelled to read this book straight through. You?re a parent. You don?t have much extra time on your hands, do you? Take a spin through chapter 1 whenever you need to give your child a medication, even a simple fever reducer. Read chapters 2 and 3 so you know how to find the right pediatrician and how to keep your kids healthy. And read chapter 4 so that you?re prepared for the unexpected. Otherwise, open it when you start to feel that uneasy sense of fear creeping in but before you?re in a full-blown panic.
When it is your child?s turn to go to the hospital, you shouldn?t leave anything to chance. As a doctor, I?ve seen too many things go wrong from the start. You need to be more vigilant about your child?s care in the hospital than anywhere. And you?ll likely have to be at your best when you?re nearly at your wit?s end and would rather become a dumbfounded bystander.
It happens to thousands of parents every day.
But don?t let it happen to you.
I want to give you tips on how to hold it together and make things go right, because I have truly been there and done that. This book provides the inside strategies that I use to get good results and avoid critical, common blunders where it matters most?in the emergency department, pediatrics ward, all-night pharmacy, exam room, or any other medical hot spot where your child?s health can be on the line. While there are plenty of books loaded with children?s health advice?believe me, I own them all?none approaches health care quite like this field guide does. It will help you make the right decisions, whether you?re just trying to get the best care for your child during a routine office visit or you?re in the middle of a full-blown health crisis.
If you live in the U.S., the odds that your child will be hospitalized this year are 1 in 25.
The great team behind this book will also help you. My coauthors include The Joint Commission?a not-for-profit organization that accredits and certifies more than seventeen thousand hospitals, health care organizations, and programs in the United States?and RealAge, a health company that provides some of the most useful free tests on the Internet, including its Healthy Kids Test. (I?m its chief pediatric officer.) Collaborating with these two organizations has yielded insights that you?ll find in no other book.
The experts at The Joint Commission impart wisdom that you?ll find invaluable (as I have) in choosing the best hospital for your child. (That?s a mission you should start right now, by the way; see page 166 to learn why.) The Joint Commission evaluates hospitals and other health care organizations to ensure that they meet top-quality standards in care, cleanliness, and procedures?and when hospitals fall short, it works to get them fixed. The Joint Commission strives to fulfill its vision that ?all people always experience the safest, highest quality, best-value health care across all settings.?
You may know The Joint Commission by way of YOU: The Smart Patient, the bestseller that it produced with two lovable guys whom I?ll bet you?re familiar with: Michael Roizen, MD, and Mehmet Oz, MD. Known to millions as the ?YOU Docs,? these physician-authors have changed countless lives through their books, TV appearances, and radio programs. They also wrote the foreword to this book. Thanks, guys!
As a parent, you work hard to teach your kids not to do certain risky things, from running with scissors to sending their e-mail address to a stranger. Moms and dads need expert guidelines too, especially when it comes to their kids? health. This book will give you my rules for dealing with the medical system?the kinds of tips that could save your child?s life one day. Even tomorrow.
And remember, it?s okay to be a little scared. It?s the sure sign of a smart parent.
? 2010 Joint Commission Resources,
How Do You Find Dr. Right?
How Smart Parents Locate Smart PediatriciansPOP QUIZ
Have you made a love connection with a pediatrician? or are you unhappy with your child?s doc? Or are you just starting to look for one? Take this quiz to find out if your search for a pediatrician is on the right track. If you can correctly answer the following questions (there may be more than one correct answer), feel free to skip to the next chapter. But if you miss a question or two, read on. (Answers can be found at the end of the chapter.)
1. When shopping for a pediatrician, what should you always ask the pediatrician?s office manager?
How many children of other doctors does this pediatrician treat?
Does this pediatrician hate middle-of-the-night calls from parents a little more or a little less than the average pediatrician?
If this is a group practice, which doctor would the office manager call in an emergency?
All of the above
A and C
2. A parent who?s tempted to call an ambulance every time her child skins a knee would probably be best served by a pediatrician whose treatment style ?
Mirrors the parent?s, so each and every concern is examined and treated immediately
Complements the parent?s by being more relaxed with a ?watch and wait? approach
3. How long is too long to regularly wait in a pediatrician?s waiting room?
Twenty to thirty minutes
Until every parent and child who entered after you has been seen
4. Even in a pinch, you should not use a retail health clinic (often found in pharmacies) to treat your child for ?
Rashes, poison ivy, bug bites, hives, or severe sunburn
Strep throat symptoms (requiring a culture test for strep throat)
Cuts or bruises that don?t require stitches
5. Never tell your child that a shot ?
Will be given to them if they keep misbehaving
Is absolutely necessary
Will be followed by a trip to the mall and a new toy
6. Which of these is something many pediatricians consider a time-wasting pet peeve?
?I forgot my checkbook?
7. What is not a legitimate reason to give your pediatrician the boot?
Not calling you back within sixty minutes after office hours, on more than one occasion
Refusing to prescribe an antibiotic for your child, even though you were sure it was necessary
Using expired vaccines
Being of little help during an emergency situation
Two weeks ago, I saw a seven-year-old girl with a severe ear infection. Her mother had found me on the Mount Sinai Physician Referral Hotline that morning.
?We love our regular pediatrician, but she doesn?t work on Wednesdays,? she explained.
Happy to be able to help but also curious, I asked, ?Not a big fan of anyone on her backup team??
?She doesn?t have a backup team,? the parent replied.
Now, this woman seemed like a typical mom. I doubt she let her daughter play on an interstate highway or with matches. But when it came to picking her baby?s doctor, she wasn?t at her brightest. If her daughter had a serious medical problem on a Wednesday, or whenever this pediatrician was unavailable, the girl would have to be treated by a doctor who knew nothing about her. A similar situation for you and your child could make a difference in how your child is cared for in critical moments, which is why choosing the right pediatrician is one of the most important decisions you?ll ever make as a parent.
?Eenie, Meenie, Minie ??
I was pretty lucky when I went through this particular rite of passage. When my husband David and I had our first child thirteen years ago, I knew just the right pediatrician for us. No, it wasn?t me. Although I?m fortunate enough to be the right pediatrician for many patients, I knew I couldn?t be objective as Dr. Mom. But I had watched the right doctor for my kids for several years. I knew her reputation in our professional circles?where flaws aren?t sugarcoated. And I had the advantage of being able to compare her skills and decisions with those of many pediatricians, including myself. I knew how this physician thought, how she reacted in emergencies, and how well she recognized her limits. Most parents don?t have all of these advantages, but they do have far more than they think.
Nevertheless, many parents select their doctor based on two things: If the practice accepts their insurance, and if the office is within a twenty-minute drive. Sure, many people ask their friends, their family members, and their own docs for recommendations, and others do a few Internet searches to see if likely pediatricians have won any awards or perhaps have a police record. Some also ask good basic questions: ?Are you affiliated with a teaching hospital? Are you board certified in pediatrics?? (See page 56 for more on board certification.)
All are good steps to take, but they could lead to dozens of pediatricians who are good doctors but not necessarily the right doctors.
So how can you find the right doctor?
Smart Shoppers Already Know the Drill
Let?s say I?m in the market for a new hairstylist?someone I can trust with my appearance and see happily every few weeks for years. Being around the corner isn?t going to seal the deal.
I will shop around and ask my friends, family, even someone in the grocery line who?s got a great haircut for recommendations. I might try out a few by getting a basic trim, or?less of a commitment?by getting an updo or blow-dry (no scissors!). If I?m not happy with the results and the person, I?ll move on until I find exactly the right fit for me.
Now, you?ve probably invested that kind of time in some sort of search. If it wasn?t choosing a stylist, perhaps it was picking out a stroller or a paint color or a preschool?or even a pair of jeans or a flat-panel TV. Finding a pediatrician shouldn?t be much different. The same or greater diligence you?d put into any of those searches should go into finding the right doctor for your child.
So let?s lay out a plan.
Pediatricians Do More than Prescribe Meds and Give Shots
Your pediatrician does many jobs, but in general you can expect the doctor to:
* Monitor your child?s growth and development
* Diagnose, treat, and explain illnesses and treatments
* Provide referrals to other specialists and work with them when needed
* Help with a potpourri of other issues: exercise and nutrition, toilet training and bedwetting, learning disabilities, emotional and behavioral problems, and dealing with death, separation, and divorce, or any other major life changes that may affect your child
Basically, you should view me (I?m standing in for your pediatrician here) as a partner whose main goal is to keep your child physically and mentally healthy.
When to Start Searching
Like any important project, searching for a great pediatrician is less daunting when you break it into small tasks and spread them out over time. If you are pregnant, start looking at least three months before you?re due. This allows plenty of time to find the child doctor of your dreams. If you already have a new baby but don?t have a regular pediatrician yet, start now so that you, your baby, and your future pediatrician have the advantage of starting a relationship as early as possible.
If you already have a pediatrician, that?s fantastic. But if you have any niggling concerns, this chapter will help you decide if that doctor is indeed right for your children and for you. You?ll either feel more confident about your choice or realize you need to press the ?eject? button and find someone else.
Start by Networking
First, get recommendations for pediatricians from the most obvious sources: your obstetrician or nurse midwife, and your own primary care doctor. If you?re adopting, which brings special concerns (see page 59), you can also ask the adoption agency for recommendations. Then ask friends, family, coworkers, and neighbors. Getting word-of-mouth referrals from people you trust is incredibly important (it?s how I get most of my patients). It?s like getting the name of a good caterer from a neighbor or an aunt?except, of course, a caterer won?t be meeting your child in an emergency department at four A.M.
When you?re asking someone for a doctor recommendation, include some or all of these questions in your friendly grilling:
Why do you like this particular pediatrician?
How long has this doc treated your child (or children)?
What?s the usual wait time in the office before an appointment?
What is the office staff like?
In an emergency, have you found the doctor to be highly accessible, either by phone or in person?
If the same one or two names keep coming up, great. Put those doctors at the top of your list. But don?t discard the others yet. There?s always the teeny chance that some of the people who give you enthusiastic recommendations 1) are satisfied with mediocre health care; or 2) have been lucky recipients of sporadic good treatment from a doctor who disappoints many other patients. You?re just gathering information now, so throw all possible candidates into the pool.
Have Some Great Candidates?
When you have at least a few names, it?s time to narrow down your list.
Let?s start with one of the biggest issues: money. Check your insurance plan to find out which pediatricians, if any, are in your insurer?s provider network. If your health insurer only covers in-network doctors, these contenders just got some stars by their names. If your insurer covers a percentage of the expenses for out-of-network docs, see ?Can Going ?Out-of-Network? Work for You?? on page 42.
Next, check out these doctors online. Start with an ordinary Google search. You may find a hospital bio page for the doctor ? or, oops, a page on a social-networking site with wild photos of the doc in Canc?n on spring break. Some general searches can also quickly give you an idea if the doctor has authored any clinical studies (good sign) or worked with local organizations (also good). Next, check the site of the American Board of Medical Specialties (www.abms.org) to be certain that candidates are board certified in specialties that focus on the care of children, such as pediatrics or family medicine. See ?What Kind of Primary Care Provider Do You Need?? (pages 56?57) for more good choices. The ABMS site can also provide you with additional candidates if your list is thin.
Can Going ?Out-of-Network? Work for You?
Having health insurance that only covers ?in-network? doctors can really limit your options. You?ll either have to choose a pediatrician from their in-network list or foot every bill yourself?and for most people, that?s not an option. However, many insurance plans will cover a percentage of the cost of a doctor who?s not in their network. If your dream doc isn?t, and you can afford the extra fees for an out-of-network doctor, it may be the right choice for you and your child.
Any Skeletons in the Closet?
Other than the one used for demonstration purposes, that is. Find out if your candidates have any nasty incidents lurking in their past. While a cursory search won?t reveal everything, check the Federation of State Medical Boards (FSMB) to see if there have been any serious disciplinary actions or professional peer reviews (trouble brewing) against the pediatrician. This is rare, but I?d sure want to know about it. In most states, the information is public and free. Find your state?s link at www.fsmb.org/directory_smb.html or call (817) 868-4000 to get the number for your state board.
Time for a Meet-and-Greet
Okay, time to call the candidates and schedule a ?meet-and-greet??a prenatal or preadoption consultation, or a consultation to switch from Dr. So-So to Dr. Right. Most insurance companies don?t cover this kind of visit, even though it?s necessary, but?good news?many physicians welcome these interviews and don?t charge for them. Still, some do. Ask when you call for an appointment.
If at all possible, bring your child along so you can see how the doc and the staff interact with her. Arrive early so you can do some stealth detective work. Look around.
Is the waiting room empty or chock-full of parents and sick, crabby kids? Neither is a great sign?unless you?re visiting at seven A.M. Or plunk in the middle of cold and flu season.
Is the place clean? (Don?t forget to check the restroom; grime is a big warning sign.)
Is the office staff polite and friendly or surly and dismissive? Did they make you and your little one feel welcome?
Does the office appear organized, or does it look like they use pitchforks to stack the file folders?
Is the waiting area kid-friendly, with dancing-bear wall decals and lots of books, toys, and games? Or is it as bleak as a police precinct?
Do the toys look clean and in good shape, or are they grimy and shabby?
Can you see yourself coming here with your child?
Chat up the other parents and ask if they?re happy with the pediatrician; if it?s a group practice, ask which docs they do and don?t like. Are the waits long? (Half an hour should be the longest.) Is getting a return call from the pediatrician difficult? Is the staff helpful when there?s an insurance snafu?
TIP: Bring your own toys! When I take my kids to the pediatrician, I always bring a couple of favorite toys from home for them to play with, especially during cold and flu season, when the office toys are likely to be germ riddled. At my office, we wash the toys regularly and disinfect them with Lysol, and we also give parents disinfectant wipes to clean toys before their kids dive in. But there?s no getting around it: Lots of sick kids touch those toys, and we can?t clean them every fifteen seconds. Quite often, at the very second a parent is ripping open a disinfectant wipe, his three-year-old is across the room clutching the truck that a two-year-old licked a minute ago. Smart parents bring their own toys. Bringing your own toys also means that they can be brought into the exam room to keep your child entertained.
Even if you?re disappointed before you even see the pediatrician, don?t leave yet. Just like a job interview, it?s worth doing, even if only for the experience.
Schmooze the Office Manager
During your visit, always?always?seek out that treasure trove of information who resides near the waiting room. Yes, the office manager. The person who knows many things. Good things and bad things. Charm some key intelligence out of this oracle. Start with small talk, throw in a genuine compliment (?Nice earrings!?), then ask the insider questions that follow. (Make a copy of them to use as a cheat sheet.)
Questions for the Office Manager
?Do you or any of your family members use this pediatrician?? If not, gently probe as to why.
?How many children of physicians does the doctor treat?? Twenty? Thirty? If it?s two, then my kid wouldn?t be the third. This can depend on your geographic area, of course. Pediatricians who work in regions that have few physicians may treat relatively few children of other doctors. But in general I?d strongly prefer a pediatrician who has the trust of other MDs.
?What are your office hours? Do you have early morning, evening, and weekend hours to accommodate working parents or emergency situations??
?How much vacation does the doctor take every year?? If it?s more than one month, hesitate. You instinctively know that your kid?s emergency will happen when ?The Doctor Is Out.? I know pediatricians who take four months of vacation a year, so definitely check this out!
?Last year, how many conferences did the doctor go to? How many continuing medical education courses did she take?? The office manager likely processes the paperwork for conferences and courses. If the response is ?Zero,? that?s a bad answer. However, ask the doctor the same question directly. Many continuing-education courses are done online now, so it?s possible the doc has taken courses the office manager doesn?t know a thing about.
?Have you ever seen the pediatrician respond to an emergency situation? Did he take control? Was he as effective as he could have been?? Ask if the doctor is typically stoic and calm in emergencies or excited and tense. Calm is better.
?Speaking of emergencies, in a life-or-death situation, which pediatrician in this practice would you ideally want to treat your child? Why?? If she doesn?t pick the doctor you?re principally interested in, you have more homework to do. Tip: The office manager may answer tactfully or cryptically, so read between the lines. If she says, ?They?re all great ? honestly, I?d feel comfortable with Dr. Jones, or any of the partners,? that means ?Dr. Jones.?
?Compared with other pediatricians you?ve worked with, how does this doctor feel about getting phone calls at home? Does it bother her a little more than the rest or a little less?? You?re really hoping for a superlative response here, like ?She doesn?t mind at all.? Something more tepid, along the lines of ?She?s not crazy about after-hours calls,? can be a telling answer.
?Compared with other pediatricians you?ve worked with, is this doctor a bit anal about keeping charts and things well organized or a little more relaxed about that stuff than the others?? You definitely want anal. (Though you don?t necessarily have to express that to the office manager.)
?How does the doctor treat the office staff?? Meaning the nurses, receptionists, clerical helpers, and the office manager, not just other docs in the practice. Ask if ?please? and ?thank you? are common, or is yelling more typical? If the office manager does some polite eye rolling or gives evasive answers, there?s a good chance that the doc is, um, a bit of a bully. Politeness may not always trump exceptional skill or talent, but it can be critical in fostering a good relationship with patients and parents. It?s one thing if a world-class specialist that you?ll only have to deal with once is a terror, but for your day-to-day pediatrician? I think niceness counts big-time. You don?t want to hesitate phoning the doc in an iffy situation because you?re worried about somebody?s bad attitude.
Now Grill the Doctor
After your incredibly fruitful time in the waiting room?which hopefully was not excessively long?you?ll be ushered back to interview the candidate. Here?s a checklist of questions I would recommend asking; add any others you like.
Questions for a New Pediatrician
Start with getting basic credentials and some personal info.
How long have you been practicing? How long have you been in this office?
Do you have children? If so, who?s their doctor? (Being a parent can help a doctor be a better pediatrician, so you might give bonus points for docs who have kids.)
What medical school did you attend? Do you have any special medical interests? Do you have any specializations?
How long have you been board certified in pediatrics or family medicine? Do you have a lifelong certification or do you periodically take recertifying exams?
Are you currently board certified in something in addition to pediatrics or family medicine?
Which hospital(s) are you affiliated with? (This could be a deal breaker if it?s not a hospital you?ve picked?see chapter 6.)
Does that hospital have a pediatric floor or wing? Is it staffed with pediatric residents for twenty-four-hour care? Is it equipped to handle pediatric emergencies? Is the hospital accredited by The Joint Commission?
The Joint Commission
The Joint Commission, a private, not-for-profit organization, has been the nation?s leader in continuously improving patient safety and health care quality for almost sixty years. The Joint Commission is the principal standards setter and evaluator for a variety of health care organizations, including hospitals, ambulatory care, behavioral health care, home care, laboratories, and long-term care. Joint Commission accreditation?the coveted Gold Seal of ApprovalTM?means that a health care organization complies with the most rigorous standards of performance. More information about The Joint Commission can be found in later chapters or by visiting its website at www.jointcommission.org.
Next, determine how well the pediatrician handles emergencies.
During an emergency, how do you prefer your patients to coordinate with you?
How do you handle late-night calls and emergencies?
Can I have your cell phone number for true emergencies?
Will you come to the ER? (If this question begets laughter, consider that a big check in the ?Keep Hunting? column.)
Will you visit my child if he or she is hospitalized? Will you continue to be the primary care coordinator if my child is in the hospital?
Next, ask about the pediatrician?s treatment experience, philosophies, and patients.
How many patients do you see on a weekly basis?
What is your viewpoint on breastfeeding? (You need only ask this if you?re seeking a pediatrician before your baby?s birth or looking for a new pediatrician while you?re still breastfeeding.)
What is your experience with children who have special needs (such as autism, ADHD, or cerebral palsy)? Ask this even if your children don?t have special needs. In my opinion, pediatricians with intense experience in treating special-needs children typically have greater patience and more finely tuned skills of perception.
What is your experience in treating adopted children and dealing with cultural issues? (Only ask this if it?s relevant to your child.)
What is your perspective on antibiotics and immunizations? (If the pediatrician?s viewpoints differ markedly from yours or from the mainstream?see pages 97 and 262?ask why.)
Add specific questions that are relevant to your child, including ones about diet and exercise issues if your child is overweight.
Next, find out how easy it will be to deal with this doctor for routine stuff.
Do you leave room in your schedule for same-day sick appointments?
Is this a group practice? If not, who fills in for you when you?re unavailable? (The more doctors in the practice, the more likely you?ll have good backup if your doctor isn?t available in an emergency.)
How do you handle phone calls? Do you have a special time set aside for parents to call with questions? If not, how long should I expect to wait to hear from you?
Do you do any quick lab tests in your office, or is all lab work sent to an outside lab? How long does it take to get results? (It?s ideal if your pediatrician does some rapid tests, such as strep throat cultures, right in the office; it saves time and hassle.)
What is your e-mail policy? Can I send you general health questions by e-mail? What about questions if my child is sick? How quickly do you tend to reply to e-mails? Is there a fee for e-mail correspondence? (Generally, pediatricians don?t charge for this, but make sure.)
Finally, it?s time to talk money. You can also get this info from the office staff, but if you have special concerns, speak directly to the doctor.
What are your fees? Do you have a list of them broken down by service?
What are your payment policies? Which insurance plans do you participate in? Do you file insurance claims or do I?
Do you charge fees to fill out forms or send copies of charts? (Pediatricians typically send out several forms per child per year to schools, after-school programs, camps, etc. Make sure any fees for this don?t come as a nasty surprise.)
Grade That Pediatrician
For your eyes only.
Did the doctor make you and your child feel comfortable?
Did the doctor explain things well? If your child is old enough to know what?s going on, did the doc explain things at a level that your child can understand and talk directly to your child?
Did the doctor listen to questions and concerns or seem rushed?
Do you share similar philosophies on child-rearing issues such as breastfeeding, circumcision, sleep problems, diet, and exercise?
Did You Make a Love Connection?
I hope so. But if you visited only one pediatrician, be skeptical about love at first sight; interview at least two more to be sure you?re going with the right person. The chemistry you felt with the doctor is just as important as the answers you got to your questions. Did you like the doc?s style? Did anything put you off? If you felt at all intimidated or talked down to, this may not be a match. If you felt rushed or just didn?t click with the pediatrician?s personality, you may not want to go forward either. A lot of people have a gut feeling when they find the right pediatrician, so listen to your inner voice.
You Be the Judge
Finally, make sure you are comfortable with the doctor?s age and gender. With a little luck, you and your children will be relying on this person?s medical care and advice for twenty years or more. Do you want to fall in love with a pediatrician who?s hitting retirement in five years? If your kids are in their teens, maybe. But if you?ve got an infant, you might want to think twice.
During the first year of your baby?s life, you will visit the pediatrician a dozen times?and that?s just for vaccinations and wellness checks. That doesn?t include ear infections, coughs, colds, or mishaps. You?d better be able to work well with this person and be thinking about the future. If you have a boy, you might prefer a male pediatrician so your son feels comfortable as he grows, especially through puberty. (Yes, your little angel will go through puberty someday.) If you have a girl, you might prefer a female pediatrician for the same reasons. (At least there are options now!)
When I chose a pediatrician for my children, I wanted a female who?d had kids herself. I know that I tend to relate to this type of physician best ? perhaps because we share the same experiences. But those are my preferences. Bottom line: Pick someone who suits your preferences. It?s okay to be persnickety.
Do Your Styles Sync?
Even if the doc seems smart, kind, and trustworthy, try to get a handle on whether his or her medical style complements yours. For instance, if you are a chronic over-the-top worrier?someone who inwardly considers calling 911 every time your child skins a knee?you may want a doctor who exudes calm and takes a ?watch-and-wait? approach (as well as one who?s skilled at talking worried parents off the ledge). However, if you tend to be the watch-and-wait type yourself, you may want a doctor with a more gung-ho, proactive treatment style who will give more intense scrutiny to symptoms you might minimize. Make sure you see eye to eye when it comes to how the doctor views your role. Does the doctor look at parents as partners or prefer to be the Lone Ranger? Make sure you both have the same expectations. Also, you need to determine if you?re more comfortable with a patient-centered or paternalistic relationship with your doctor.
I?ll explain. There was a time not so long ago when the patient was in the backseat and the doctor drove the proverbial bus?that is, made all the decisions. Most patients went along with this and tended to view MDs as all-knowing.
Today, however, far fewer doctor-patient relationships fit this paternalistic paradigm. People now have access to almost unlimited medical information via the Internet, TV, books, and magazines. While most people still want and need the knowledge and experience doctors bring to the equation, many also want to be part of the health care process. In fact, one study found 86 percent of parents are likely to participate in decision-making with their doctor. But it also found that those who wanted a paternalistic relationship with their physicians were quite happy with doctors who had the same mind-set.
I strongly prefer parents who view our relationship as a partnership. We are in it together. I provide medical expertise and know-how. You offer information that helps me diagnose and treat. And, of course, you make your final decisions with my guidance.
You also help me help your child?for example, by making sure medications are taken or symptoms are treated or a blood test is scheduled. We really do need each other, and that includes deciding on treatments together. It?s best if we?re both fully invested in the final outcome: good care and good health for your child.
These roles need not be absolute, by the way. You may want to have a patient-centered relationship, but during emergencies you expect your pediatrician to assume a paternalistic role and take charge. Whatever you envision, talk to the doctor about how you see your role. Personally, I feel like if you?re involved in the decision-making, you will be happier with the outcomes.
Speaking of Styles ?
As a doctor and a mom, I know how important it is for my style to complement the styles of my patients? parents. I always give my office number to parents and tell them to call me if they have further questions or forgot to ask something. I want them to know from the get-go that it?s okay to call me. There are no silly questions, just questions that parents may not know the answers to. I?m not bothered by questions, and the right pediatrician for your child shouldn?t be either.
What Kind of Primary Care Provider Do You Need?
The right doctor for your child doesn?t have to be a pediatrician. It may be one of the experts listed below. You need to figure out who will be the best choice for you and your family. Your decision may also depend on the age of your kids and the health care choices where you live. Here?s who does what:
Pediatricians focus on kids? physical, emotional, and social health from birth through young adulthood. They work hard to treat health problems, but they work even harder to prevent trouble by making sure kids have immunizations and regular checkups and eat and sleep properly. Pediatricians must complete four years of medical school and three years of pediatric residency. To be board certified, they must pass a written exam given by the American Board of Pediatrics and then be recertified every seven years. To be eligible for license renewal and to care for patients, a pediatrician must also obtain continuing medical education credits. These are designed to keep doctors up-to-date on the latest medical practices and procedures.
Family physicians also have to complete four years of medical school and three years of residency, which often includes training in pediatrics and/or other areas such as internal medicine, orthopedics, and gynecology. Family physicians are qualified to provide basic care for patients of all ages. To be board certified, they must pass a written exam given by the American Board of Family Medicine and then be recertified every seven years. To be eligible for license renewal and to care for patients, a family physician must also obtain continuing medical education credits. These are designed to keep doctors up-to-date on the latest medical practices and procedures. A family physician can see your child from birth through adulthood, but make sure you ask about age policies since some family physicians don?t see children younger than a certain age.
Pediatric nurse practitioners (PNPs) have a master?s degree in nursing and get special training in performing physical exams, taking medical histories, and making basic diagnoses in children. If PNPs encounter a complicated medical problem, they?re trained to consult with the doctor. PNPs are increasingly popular in group practices because they have the knowledge and time to, say, go over a treatment again when the doctor?s already seeing the next patient.
You?re Being Interviewed Too
?I?m sorry, I?m not able to take your child as a patient due to my current workload, but I can recommend some other pediatricians who might have more open schedules.?
A pediatrician who delivers this line may be telling the whole truth. Perhaps they really couldn?t wedge another patient into their schedule with a crowbar. Or they might be telling a half-truth ? they wouldn?t wedge you into their schedule with a crowbar. Why? Evaluations go both ways, and docs decide whether they can work with you, too. We may realize our treatment style doesn?t sync with yours or just sense that the chemistry between us is off. Or you may ring our alarm bell because you ?
? have changed doctors a dozen times in the last five years. That?s a red flag that you?re not going to be satisfied with any medical professional.
? were a problem parent for a pediatrician five towns away. What, you think we don?t talk to each other? If you had a blowup with Dr. Jones, let Dr. Smith know?briefly, accurately, and without casting aspersions on Dr. Jones.
? have been mysteriously cryptic about your child?s medical past or refused to provide medical records (especially records of consultations with specialists). This often means that a parent already has a fixed viewpoint about a particular issue, such as the source of their child?s symptoms, and is shopping for an agreeable doctor who will give them the opinion they want to hear and prescribe the treatment they want rather than actually provide independent medical expertise.
Pack Rat Permission Granted
Once you?ve picked your pediatrician, don?t throw away that voluminous pile of information you?ve collected. What if your wonderful doctor moves out of town? Or decides to quit medicine and hike across America? Or what if a few years from now your daughter doesn?t want to see a ?boy doctor? anymore? Or your insurance changes and excludes your current pediatrician? Hanging on to that info means you won?t have to start over from scratch.
? seem like a ?headline parent.? See page 260 in chapter 8 for more on this merry phenomenon.
If you haven?t started keeping meticulous records of health history and medical care for yourself and your child, please consider yourself nudged in that direction. Good family medical records are so vital that they?re a recurring theme in this book. If you haven?t started keeping them, it?s never too late.
The first step I?d recommend is going to the American Academy of Pediatrics (AAP) website and using the Care Notebook you?ll find there (www.medicalhomeinfo.org/tools/care_notebook.html). The notebook is an organizing tool that will help you become an expert on your child?s and family?s health care. You can pick and choose from dozens of handy forms that will help you track immunizations, allergy records, doctor appointments, hospital stays, growth patterns, family and medical history, nutrition, insurance providers, and therapists. There?s an online tour to walk you through the steps of putting the Care Notebook together. And you?ll find the AAP site is super-useful in general.
MEDICAL RECORDS FOR ADOPTED CHILDREN
Adoption is more popular among Americans than ever before. Each year, about 125,000 native-born children are adopted, and another 23,000 or so children are adopted from countries outside the U.S.
If you adopt a child through a U.S. agency, you should receive a complete medical record for your child to share with your pediatrician. Unfortunately, medical records for children adopted from other countries are not always complete or reliable, and usually the only source of information is the agency or orphanage from which you adopted. Nevertheless, try to obtain as much information as possible for your child?s medical records.
First, you want to learn about the birth parents, including their age, height, weight, ethnicity, education (which can impact their health care), and any medical conditions the mother and father had.
Second, ask what health care the baby has had since birth. Try your best to get immunization records and growth charts.
For more information on medical records for adopted children, check out these resources.
Web page on adoption and foster care at the American Academy of Pediatrics (AAP) website
The National Council for Adoption
Website of the National Adoption Information Clearinghouse
Website of the State Department with info on international adoptions
Link to national magazine for families who are planning to adopt or already have adopted children
The Child Welfare Information Gateway, which contains info on both adoption and foster children
Foundation created by Wendy?s founder Dave Thomas, who was an adopted child
Website of the American Association of Open Adoption Agencies
Electronic health records (EHRs) are here to stay, in part because the federal government wants everyone to have an EHR within ten years as a way to reduce medical errors, improve efficiency, and cut health care costs. So if your pediatrician already uses them?roughly 20 percent do at the moment?you might want to get started. Why? As more and more doctors and hospitals move to EHRs, you?ll soon be able to say, ?Doctor, can you e-mail me my son?s lab results?? Not only will you have them quickly and precisely but you can then copy those results into your own electronic records.
Yes, there are privacy concerns, but frankly, that?s true of paper records, too. According to a study done by the Los Angeles Times, roughly 150 people (doctors, nurses, technicians, billing clerks) have some access to a patient?s medical record during a hospitalization. And that doesn?t include insurers and other billing companies. That?s why there are strict privacy rules designed to make sure health care information is secure?surely you remember those gazillions of HIPAA (Health Insurance Portability and Accountability Act) forms we had to sign back in the late nineties!
Prepping Your Child?and Yourself?for a visit
The first year or two of your child?s life will include regular wellness visits to the pediatrician to check on growth and development, get vaccinations, and just generally make sure everything is going along fine. But little ones have steel-trap memories, so if your toddler equates going to the doctor only with getting shots, you may find yourself with some ?splaining? to do. (?So that?s why the nurse often gives the shots,? you?re thinking. ?Now I get it.?) Kids need to understand that docs do a lot more than give shots?tell them that we help kids stay healthy and get well. Whether they are going in for a routine exam or because they are injured or sick, you can help quell their fears.
Explain why you?re going. If it?s for a ?well-child visit,? tell your children the doctor wants to make sure they are growing and that healthy kids go to the doctor to be sure they stay that way. They need to know that going to the doctor is not a punishment for any misbehavior. Some kids actually believe this. Really. Not only do some parents not dispel this wrong belief, but I?ve known a few to even use it as a threat. (?If you don?t stop throwing the kitten into the bathtub, I?m going to take you to get a shot!?) Naturally, this makes me and other pediatricians crazy! I want kids to think of my office as the place with the cool bears on the wall, not where they go to be punished for putting chewing gum in their sibling?s hair.
If your child is ill, explain that the ?doctor will help you feel better.? Occasionally younger kids feel guilty about being sick, so assure them that the illness isn?t caused by anything they did. Say something like ?Sometimes children get sick, and we?re lucky to have doctors who can find out why and help you get well.?
It?s okay to admit to your child that you don?t know what?s wrong but that you?ll all work together with the doctor to find and fix the problem.
If your child has an embarrassing problem, like bedwetting or head lice, make sure you explain that it?s not their fault and that it happens to many children. Kids often feel incredibly embarrassed or guilty about things like this, so discuss it in reassuring language and then put on your best ?no biggie? attitude.
Tell your child what to expect. Basically, play doctor with them at home with a toy medical kit. Use a doll or stuffed animal to show how the doctor will look in the mouth, eyes, and ears, and listen to the heart with a stethoscope. Explain that the doctor may listen to the tummy, tap the knees, look at the feet, and glance at their ?private parts? to make sure everything?s healthy. Assure your child that you will be there during the entire exam. Don?t forget to bring a favorite doll or stuffed animal along. Like me, your pediatrician may even give Mr. Ted E. Bear an exam, too. No charge.
Speaking of private parts, most kids are taught that no one should touch them there, so explain that sometimes their bodies need to be examined everywhere, including there, to keep them well. Please also explain the differences between appropriate and inappropriate touching, even by a doctor, nurse, mom, dad, or grandparent, not to mention a friend or stranger. Your pediatrician can give you some pointers on how to go about this if you?re not sure.
It?s Just Between Us ? Unless It?s Serious
As kids reach adolescence, they may stop talking to you about certain issues. Boys may prefer to go to the doctor with their dads, and girls with their moms. If you?re the one being shunned, your child still loves you. This is normal, and you can rest assured that the shunning will cease when they?re old enough to need a big bump in their allowance or to borrow the car keys. When my patients turn twelve, I create a contract with them. I see them first with a parent and then without. This gives tweens and teens a chance to ask and answer my questions free of embarrassment or fear regarding important issues such as sex, alcohol, smoking, and drugs. My patients also know that if they?re doing something to physically hurt themselves, or someone else, I have an obligation to tell their parents.
Let your child know if a procedure is going to hurt a little or be embarrassing, but be a little vague on the details so that you don?t create unneeded fears.
Watch your language. If you tell your five-year-old that the doctor will need to ?take blood,? explain that it will only be a teaspoon or two. Some kids worry that all their blood will be taken! (I?m not kidding.)
Ten Tips for the Perfect Office visit
?You need to bring her in.? I know you probably don?t want to hear those words, but in many cases, I simply can?t answer questions without seeing a child. I?ll do what I can to save parents a trip to my office, and many cases can be handled over the phone. But not all. Every child is different, and there are nuances and symptoms that I must physically see in order to diagnose and treat the child. During a sick visit?or any visit for any reason, for that matter?use these ten tips to be a smart communicator and to help your child get quicker treatment.
Don?t Be Shy. Bring a list of questions, starting with the most important ones. Don?t be shy about checking your list or taking notes. I?ll be impressed that you came prepared. (Just wait to fire away until I have the stethoscope out of my ears.)
Sick ? How Long? Please write down what the symptoms are and when each one started. The pattern can make it easier to diagnose problems.
Paint Me a Picture. If your child is taking any medications, bring those along. That includes vitamins, herbals, and over-the-counter remedies.
Doc, Have You Seen That Study on the Web? It?s great when you come in with information you found on the Internet, in a magazine, or elsewhere. Hey, docs love it when you are well-read and actively involved in your child?s care. But it?s hard for us to evaluate every health tidbit on, say, the Discovery Channel. If you want us to review some bit of info, e-mail it, fax it, or drop it off in advance, so that we have time to check it out before your office visit. At the same time, give pediatricians a little credit for two things: medical school and years of experience. I see a lot of kids every day, and I may have had experiences that the writer of the USA Today article you?re panicked about does not.
Attention, Please. Be focused during the visit. Try to leave other children at home with a sitter. Please turn your cell phone off, too. You want our attention and we want yours.
Promptness Pays. Arrive on time or even early. We don?t want to keep anyone waiting, but if half our patients arrive late, well, you can see why we might run late too.
Huh? I Don?t Get It. If you don?t understand something, please ask us to explain it again or in simpler language. We try not to get into doctor-speak, but it happens. Rein us in.
A Sketch, Perhaps? Would a drawing help to explain a problem or procedure? Sometimes kids and parents can relate better to a picture that shows why an ankle hurts, for example, or a stomach doesn?t feel right.
Prefer Parents. If at all possible, a parent?not a nanny or a sitter?should accompany kids on doctor visits. With working parents, I know that?s sometimes tough, but sitters and nannies don?t always get the information straight. Also, I may have questions they can?t answer. (Another reason why it?s preferable to find a pediatrician with evening and/or Saturday hours.) If it?s not possible for a parent to come, I will call Mom or Dad before the visit to get the child?s history and afterward to give a parent any treatment instructions.
Can You Tell Me Again What You Said? Don?t forget to follow up. If you get home and think, ?What was that tip about using the inhaler?? call or e-mail to be sure. It doesn?t hurt to ask for written explanations or instructions before leaving your doctor?s office, either. That way, you?ll have all this information in writing before you?re out the door. Also, call about test results. No news is not necessarily good news.
One Thing Not to Do
Doctors call them ?doorknob moments.? It?s when the visit is wrapping up, we have our hand on the exam room doorknob to leave, and a parent says, ?Wait ? do you think Matthew could be vomiting because he fell down the stairs??
Maybe you?re anxious about telling the doctor something so you save it for last. (?I gave him two tablets instead of one ? could that be a problem??) It?s understandable. But here?s the thing. We need you to be open about everything during the initial discussion so that we don?t miss important clues that could change the diagnosis or treatment. Still, if you do remember something at the last minute, don?t be afraid to bring it up. We?d rather have the full picture, doorknob moment or not. And here?s a tip that might help: Write down your questions and your child?s symptoms before you come.
I Don?t Want to Go to the Doctor!
It?s a sad fact; not all of my patients love seeing me all of the time. I don?t take it personally. Sometimes, kids will open up about why they?re afraid of going to the doctor, but more often they remain silent and stew privately. Here?s what you need to know, even if they don?t tell you.
Kids worry about pain, especially six- to twelve-year-olds when it comes to shots. Remind them that it stings or pinches for only a second.
Kids are afraid their parents will leave them alone in the examination room. This is more common in children under seven, but it can happen through age twelve. Tell them you will stay with them throughout the visit.
Like us, children worry about the unknown. Some kids fear that they are really sick and their parents aren?t telling them the truth. If they need surgery or hospitalization, some kids equate that with death, especially if someone they loved and knew, like a grandparent, died after being in the hospital. Offer reassurance and tell your child that the doctor and hospital staff will make sure they feel better and get well. (See chapter 7 for more info on getting through a hospital experience.)
While it?s hard for a pediatrician to be as popular with kids as a cartoon superhero, most docs try to make the experience as pleasant as possible. If your pediatrician seems disinterested or doesn?t communicate with you or your child well, it may be time for a change.
The Deal on Retail Health Clinics
You?ve probably seen the drop-in medical centers in big-box stores like Target or Wal-Mart and in drugstore chains like CVS or Walgreens. There are about a thousand of these ?convenient care clinics,? ?mini clinics,? or ?minute clinics.? As a rule, they handle only common ailments and are staffed by physician assistants and nurse practitioners (NPs), who can order tests and write prescriptions. The cost is relatively low, at about $50 to $75 a visit (or an insurance copay), and the wait is not long. No wonder the clinics are popular with the young and uninsured. Less than half of those who use the clinics have a primary care doctor, which means they serve a good purpose.
So is it okay to take your child there on Sunday night if you think he has strep throat? I would advise you to call your doctor first, but if you do go to a clinic, follow up with your pediatrician as soon as possible. If I couldn?t get to my pediatrician?s office, I?d feel relatively comfortable using one of these clinics for the following common problems:
Rashes, poison ivy, bug bites, hives, or severe sunburn
Strep throat symptoms (requiring a culture test for strep throat)
Cuts or bruises that don?t require stitches
The American Academy of Pediatrics opposes the use of retail clinics for children and adolescents, though, because it feels pediatricians use even minor visits to address family issues and to check on immunizations, among other things. The AAP is also worried about continuity of care, which is a concern I share, too. In sum, use them if you?re in a pinch, but let your doctor know so that he has a record of the illness and what was done about it.
Speed Bumps Happen
Sometimes, a relationship with a doctor can hit a speed bump?a conflict of opinions, a failure to communicate, a misunderstanding that gets tense. Now what? Here are some ways to ease through a potential rough patch with your pediatrician.
If you disagree about something?say, the need to repeat a blood test on your kid several times to make triply sure a disease isn?t missed?have a prompt conversation with the doctor (without your child present) and express your concerns. You both have your child?s best interests at heart. Don?t let things fester.
If a medication or some other treatment is prescribed, ask your doctor how long it should take to work and what to do if it doesn?t. And if you think it doesn?t, call and calmly explain the facts. Ask if something else can be tried or if there is any other condition or disease that might have been overlooked. This is perfectly acceptable language as long as there?s no accusatory tone. Talk through all possible courses of action. Maybe the problem is less medical and more behavioral and it?s time to try a therapist. Doctors want to help, but try as we might, we?re not perfect.
Don?t hesitate to bring up an iffy experience in the office, whether it was from the front desk, from the business administrator, or in the exam room. If you felt rushed, say so. If you need more information, speak up. We want to do the best job possible, but we?re not clairvoyant. Feedback is great, and I welcome it.
Time to Fire Your Pediatrician?
If you have a pediatrician who would fail the vigorous ?exam? outlined in this chapter or who just frustrates you (do you tend to leave the office more confused than when you entered?), you and your child deserve better. There are many things that could spur you to tell your pediatrician sayonara, but here are some of my deal breakers:
It takes months to get an appointment.
The wait time to be seen for a scheduled appointment regularly exceeds twenty to thirty minutes (and the parent and child are on time).
The doctor didn?t return an after-hours phone call or page within sixty minutes. (During busy office hours, give your doc a little more time.)
The pediatrician was of little help during a hospitalization or an emergency situation.
There?s a pattern of the pediatrician not answering questions or dismissing multiple questions as unimportant.
When the pediatrician was out, there wasn?t adequate backup (referring patients to a hospital emergency department instead of having another doctor cover isn?t adequate).
Resources for General Health Information About Children
American Academy of Family Physicians (AAFP) (www.familydoctor.org)
Explore a wealth of practical information on diseases, conditions, medications, symptoms, healthy living, and more.
American Academy of Pediatrics (AAP) (www.aap.org)
Go straight to the Parenting Corner for advice on choosing a physician, immunizations, child development, safety and injury prevention, and more.
Centers for Disease Control and Prevention (www.cdc.gov)
This is the place for official government health data and recommendations for kids from birth to age twenty. You will find interactive tools, charts, growth tables, recommended vaccinations, and information on infectious and chronic diseases, injuries, disabilities, and environmental health threats.
Here you?ll find practical, easy-to-read articles on a range of diseases and chronic conditions. There are also doctor-approved resources and information. The site is divided into unique areas for parents, children, and teens.
U.S. Department of Health and Human Services (www.healthfinder.gov/kids/)
Check out this site with your kids! Includes games, contests, pointers on how to surf the Net safely and create personal sites, plus information on substance abuse, safety, and more.
Yuckiest Site on the Internet (www.yucky.com)CHAPTER 2 POP QUIZ ANSWERS
Explore a range of fascinatingly yucky science topics with your kids. The site includes a section on understanding the gross and cool human body.
1. When shopping for a pediatrician, what should you always ask the pediatrician?s office manager? The answer is D, all of the above. (Page 45.)
2. A parent who?s tempted to call an ambulance every time her child skins a knee would probably be best served by a pediatrician whose treatment style ? The answer is B. This parent should seek out a pediatrician who usually takes a more relaxed ?watch and wait? approach. (Page 54.)
3. How long is too long to regularly wait in a pediatrician?s waiting room? The answer is B, twenty to thirty minutes. On occasion you may get a longer wait, but with children in the equation, you need an office that keeps things moving. (Page 70.)
4. Even in a pinch, you should not use a retail health clinic (often found in pharmacies) to treat your child for ? The answer is C, breathing difficulty. (Page 68.)
5. Never tell your child that a shot ? The answer is B. Can you believe that a lot of parents actually use this threat? (Page 62.)
6. Which of these is something many pediatricians consider a time-wasting pet peeve? The answer is A. (Page 66.) You know, that doorknob thing!
7. What is not a legitimate reason to give your pediatrician the boot? The answer is B. On the contrary, refusing to give you an antibiotic even when you lay on the pressure is probably a sign that your doctor is quite prudent. (Page 69.)
? 2010 Joint Commission Resources, Continues...
Excerpted from The Smart Parent's Guide by Jennifer Trachtenberg Copyright © 2010 by Jennifer Trachtenberg. Excerpted by permission.
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