Friday, March 11, 2016
"You're the doctor!"
It's normal practice, when rounding on children in the morning, to ask the parents how the child is doing. It isn't useful for the parents to snap back, "you're the doctor, you tell me!" This is a two way street. We have to communicate.
Monday, February 29, 2016
Tests
If you ask old doctors, they will unanimously say that the younger set of doctors relies way too heavily on getting tests. Your history and exam should tell you the diagnosis, they say; tests are to confirm what you already know is there. Spend more time talking to and examining the patient, and you will find out what is wrong with them easily.
There are many situations where I can do just that. I spent years learning the art of history taking and physical diagnosis, and don't need that many tests. That's why I get so annoyed when parents demand them. I really don't get that irritated when parents just ask if I shouldn't be doing some (unspecified) test. But I do get ticked when parents with no medical training whatsoever (except, I guess, from Google U) think they know just WHAT tests I should be ordering. News flash: that was also part of my training. So was risk-benefit ratio. That CT scan you're demanding won't tell me anything I need to know; and will expose your child to a shocking amount of ionizing radiation that will put him or her at higher risk of cancer down the road. And if it is a belly CT, their reproductive organs will get irradiated. You are putting not only your child, but your future grandchildren, at risk. If I feel that a CT is necessary to care for your child, I certainly will not hesitate to get one. But I don't like to get any testing if I don't have something useful to learn from it. Please, let me do my job.
There are many situations where I can do just that. I spent years learning the art of history taking and physical diagnosis, and don't need that many tests. That's why I get so annoyed when parents demand them. I really don't get that irritated when parents just ask if I shouldn't be doing some (unspecified) test. But I do get ticked when parents with no medical training whatsoever (except, I guess, from Google U) think they know just WHAT tests I should be ordering. News flash: that was also part of my training. So was risk-benefit ratio. That CT scan you're demanding won't tell me anything I need to know; and will expose your child to a shocking amount of ionizing radiation that will put him or her at higher risk of cancer down the road. And if it is a belly CT, their reproductive organs will get irradiated. You are putting not only your child, but your future grandchildren, at risk. If I feel that a CT is necessary to care for your child, I certainly will not hesitate to get one. But I don't like to get any testing if I don't have something useful to learn from it. Please, let me do my job.
Tuesday, July 14, 2015
You paged me-where are you?
I only see patients that are sick enough to be hospitalized. For that reason, I really hate when I return a page from an office doc only to be put on hold by a receptionist who has no clue why I'm being paged (or even that someone paged me). I don't mind holding for a minute or so while they get the doc. I mind holding for 10 minutes while the doc finishes whatever he's doing. Or even longer because they don't page me to the back line, and I have to go through the damn phone tree. I am supposed to be taking care of sick kids, not sitting on hold with my thumbs up my ass.
Monday, December 22, 2014
Happy Holidays!
Quick time out to say happy whatever-if-any-winter-holiday-you-celebrate. And thanks to the donors who allow the kids in hospitals over the holiday (well, at least in mine) to be spoiled rotten in return for having to be there.
Wednesday, October 29, 2014
"My doctor didn't DO anything!"
Parents tend to expect the "miracles of modern medicine." When they take their sick little one to the doctor, they expect that doctor to do tests, instantly discover exactly what is wrong with the child, and prescribe curative treatment. If that doesn't happen, they think their doctor "didn't do anything."
When I see a sick child, I start by taking a history. Much of the time I spent learning what questions to ask seems wasted, though, because no one wants to give me any detailed answers. I frequently get such vague, uncommunicative answers that I wonder if the parents actually live with the child. They certainly don't seem to know much about the child. I was trained to use the answers to my initial questions to guide further questions. This is often met with impatience, as parents don't seem to understand why I need this information.
After I have given up on prying any more information out of the parents, I examine the child. Small infants are pretty easy; the worst thing they can do is puncture my eardrums by screaming while I try to listen to their lungs. Toddlers don't understand what I am doing, and I don't blame them for resisting; but the little shits are strong, and often leave bruises. The trauma of a toddler exam-to both the child and the doctor-can be minimized if a parent will help. Too often the parent is texting and ignoring the kid. Even if they aren't, many don't want to hold the kid still enough. While I don't mind being hit or kicked by toddlers, I DO mind that behavior from supposedly normal school-aged kids. I understand that a medical examination is unpleasant and scary. But school-aged kids are old enough to understand that they need to hold still for a few minutes. I have seen kids who are never made to obey at all. I have seen kids who hit and kick their own parents-who just sit there and take it. However, I get as thorough an exam as I can.
Once I have done that, I put the history and physical findings together to figure out what is most likely going on. I may need to do tests to confirm my diagnosis; I may not. I don't do tests that I don't think are necessary, because I find it unethical.
After I have examined the child, and decided if I need tests, I can recommend the best course of treatment. Believe it or not, sometimes the best thing to do is rest and fluids. At home. This is when it gets hairy. You see, all I did is talk to the parents and poke the kid, then gave the same advice they already got from their grandmother. No zillion-dollar tests to pinpoint the EXACT problem. No unpronounceable medications that were in TV ads. No CURE. Why the hell would I just tell them the kid has a cold? How lazy can I get? They will go somewhere else, and keep doing so until they find a doctor who will DO something.
I spent a lot of time in training to learn when to do what. If the kid has a viral upper respiratory infection-a cold-there is no need to know which virus it is. It's all treated the same. By treating the symptoms. No antibiotics. If a baby spits up, try smaller feedings, not a cat scan and drugs. Have some sense. Please. You can even get it without a prescription.
When I see a sick child, I start by taking a history. Much of the time I spent learning what questions to ask seems wasted, though, because no one wants to give me any detailed answers. I frequently get such vague, uncommunicative answers that I wonder if the parents actually live with the child. They certainly don't seem to know much about the child. I was trained to use the answers to my initial questions to guide further questions. This is often met with impatience, as parents don't seem to understand why I need this information.
After I have given up on prying any more information out of the parents, I examine the child. Small infants are pretty easy; the worst thing they can do is puncture my eardrums by screaming while I try to listen to their lungs. Toddlers don't understand what I am doing, and I don't blame them for resisting; but the little shits are strong, and often leave bruises. The trauma of a toddler exam-to both the child and the doctor-can be minimized if a parent will help. Too often the parent is texting and ignoring the kid. Even if they aren't, many don't want to hold the kid still enough. While I don't mind being hit or kicked by toddlers, I DO mind that behavior from supposedly normal school-aged kids. I understand that a medical examination is unpleasant and scary. But school-aged kids are old enough to understand that they need to hold still for a few minutes. I have seen kids who are never made to obey at all. I have seen kids who hit and kick their own parents-who just sit there and take it. However, I get as thorough an exam as I can.
Once I have done that, I put the history and physical findings together to figure out what is most likely going on. I may need to do tests to confirm my diagnosis; I may not. I don't do tests that I don't think are necessary, because I find it unethical.
After I have examined the child, and decided if I need tests, I can recommend the best course of treatment. Believe it or not, sometimes the best thing to do is rest and fluids. At home. This is when it gets hairy. You see, all I did is talk to the parents and poke the kid, then gave the same advice they already got from their grandmother. No zillion-dollar tests to pinpoint the EXACT problem. No unpronounceable medications that were in TV ads. No CURE. Why the hell would I just tell them the kid has a cold? How lazy can I get? They will go somewhere else, and keep doing so until they find a doctor who will DO something.
I spent a lot of time in training to learn when to do what. If the kid has a viral upper respiratory infection-a cold-there is no need to know which virus it is. It's all treated the same. By treating the symptoms. No antibiotics. If a baby spits up, try smaller feedings, not a cat scan and drugs. Have some sense. Please. You can even get it without a prescription.
Tuesday, August 26, 2014
Patient satisfaction
I want to preface my post by saying that I snark and bitch about a lot of things. It's the whole reason I created my blog. But most of those things are relatively minor. They don't diminish my love of being a doctor. What I am about to talk about does diminish that love. It makes me wonder if I am in the wrong career.
I spent years in medical school, residency and fellowship to learn how to diagnose and treat patients. I put my adult life on hold while I did this, and went hundreds of thousands of dollars in debt for school. After training, I spend hours in continuing medical education so I can keep up on the latest science-based treatments.
However, I seem to have wasted my time. You see, now insurances have tied reimbursements to patient satisfaction. If the patient satisfaction scores are good, the hospital gets paid. If they aren't, no pay. I want my patients to be satisfied that they got good medical care with appropriate communication. But that isn't what makes high satisfaction scores. That comes when families get what they want-regardless of what they need. The parents of a child with functional abdominal pain (meaning belly pain without any identifiable cause) will INSIST he needs a CT scan. Never mind that he has had 3 normal ones in the last 2 months. Never mind that CT scans have a crapton of radiation, and the kid is being put at increased risk of cancer. And their grandkids will have 3 heads.
The family of a kid with heartburn doesn't want to hear that maybe the kid should eat less fried and spicy food, and not eat at bedtime. No, they want an endoscopy to find the problem. Not only does the procedure itself carry inherent risk, but it usually requires sedation. That only adds risk.
Parents Google their kids' symptoms, decide what they think the kid has, and what tests and treatments they need. We, as medical professionals, are supposed to provide whatever is demanded. When we don't, people complain. After all, they are paying us to do whatever; we should do whatever they want.
I want to make myself very clear. You are NOT paying me to just order whatever you tell me to. You are paying me to assess your child, decide what diagnostic tests are appropriate, interpret them, and come up with a treatment plan. If what you really want is to diagnose and treat your own child with help from the internet, write your own damn orders. I have better things to do than take dictation.
I spent years in medical school, residency and fellowship to learn how to diagnose and treat patients. I put my adult life on hold while I did this, and went hundreds of thousands of dollars in debt for school. After training, I spend hours in continuing medical education so I can keep up on the latest science-based treatments.
However, I seem to have wasted my time. You see, now insurances have tied reimbursements to patient satisfaction. If the patient satisfaction scores are good, the hospital gets paid. If they aren't, no pay. I want my patients to be satisfied that they got good medical care with appropriate communication. But that isn't what makes high satisfaction scores. That comes when families get what they want-regardless of what they need. The parents of a child with functional abdominal pain (meaning belly pain without any identifiable cause) will INSIST he needs a CT scan. Never mind that he has had 3 normal ones in the last 2 months. Never mind that CT scans have a crapton of radiation, and the kid is being put at increased risk of cancer. And their grandkids will have 3 heads.
The family of a kid with heartburn doesn't want to hear that maybe the kid should eat less fried and spicy food, and not eat at bedtime. No, they want an endoscopy to find the problem. Not only does the procedure itself carry inherent risk, but it usually requires sedation. That only adds risk.
Parents Google their kids' symptoms, decide what they think the kid has, and what tests and treatments they need. We, as medical professionals, are supposed to provide whatever is demanded. When we don't, people complain. After all, they are paying us to do whatever; we should do whatever they want.
I want to make myself very clear. You are NOT paying me to just order whatever you tell me to. You are paying me to assess your child, decide what diagnostic tests are appropriate, interpret them, and come up with a treatment plan. If what you really want is to diagnose and treat your own child with help from the internet, write your own damn orders. I have better things to do than take dictation.
Saturday, July 19, 2014
Public Service Announcement
This is for the parents who allow their kids to be brats at the hospital or doctor's office. Yes, I know that pediatricians and their nurses are expected to use "child-friendly" language at all times. However, if your demonspawn bites someone, don't be shocked if they react with four-letter words. If you don't want to hear your kid referred to as a little shit, don't let him be one.
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