"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.

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.

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.

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.

"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.

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.

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.

Vaccine Package inserts

I am pro-vaccine.  I just wanna get that out there.  That said, I have seen a lot of anti-vaccine activists making arguments and supporting themselves by citing the package insert-somewhat erroneously.

For starters, those inserts are not like food labels; that is, they are not meant to educate the general public.  For one, they are geared toward medical professionals.  They are not written in lay language.  Two, they are mostly a legal document.  They have to tell the ingredients.  When it comes to side effects, that's where the confusion starts.  You see, during a clinical trial, any symptom that develops is assumed to be from the experimental drug.  If a test subject reports that he farted, then "flatulence" will be listed as a side effect.  It does not matter if the symptom is actually related to the drug.  If I were in a trial right now, and was asked if I had pain, I would have to tell them my foot hurts.  They would put "foot pain" as a side effect of the drug-even though I broke my damn foot last week, and THAT is why it hurts.

Because they are not written in lay language, a lot of people misinterpret.  When the insert says, correctly, that a small number of patients don't respond, people take that to mean that the vaccine never works and is useless.  While we're on that subject, many of them will say something like "studies have proven that this vaccine induces an immune response.  No study has proven that there is a decrease in disease incidence with this vaccine."  Again, that is a lawyer-mandated CYA comment.  Of course there isn't such a study.  You'd have to get a big group of  people, randomly give half of them the vaccine and the other half a dummy shot, then (after giving the immune system time to respond) expose them all to the active disease and see which group gets sick more.  That violates human research ethics in so many ways.  Intentionally give people disease?  Google "Tuskeegee Syphilis Study" and read about it.

I get really mad when people go on about how much better immunity is when induced by "a simple childhood illness."  Ummm, the point of the immunity is NOT TO GET THE ILLNESS.  It isn't always sneeze twice and go on with life.  In the interest of full disclosure I will say that I do not now, nor ever have in my career, make ONE SINGLE PENNY from vaccines.  But I want these illnesses eliminated.  I only see sick kids; I wish my whole specialty would become unnecessary because all kids were healthy.

I attended the most appalling committee meeting today.  The meeting discussed using an electronic tool to track "quality measures" of a doctor's performance.  The members of the committee had to decide what to measure (mostly bullshit paperwork), how to measure it, and how to discipline docs who don't meet expectations.  It was bad enough that very few of the measures had any real meaning.  What appalled me is that the committee consisted mostly of administrators and nurses-only 2 docs.  It wasn't that my colleagues didn't come; most of them weren't invited (I don't know how I was; I'm not usually on that committee).

Patience, grasshopper.

Yesterday I admitted a kid with pneumonia.  He looked pretty miserable, with a  high fever, working to breathe and needing oxygen by face mask.  I started him on treatment and told his parents it could take a few days.
Today, when I made rounds, his mother accosted me anxiously.  She wanted me to "run more tests" since, according to her, he wasn't getting any better (in less than 24 hours!).

When I went in to look at him, his fever was much lower.  He was breathing more easily.  He needed less oxygen, and was even hungry.  Needless to say, I did NOT order more tests.

I don't treat to order.

I am SO annoyed by parents who think they know everything.  We occasionally get parents who decide, at home, what treatment their child needs.  Since that treatment has to be provided by a doctor, they bring the kid in.  Not to have the doc evaluate the kid and recommend a treatment course.  Just to have the doc provide the treatment that the parents already decided they want.  The parents get so pissed when I insist on examining the child and offering only appropriate treatments.  Medicine has gotten so commercialized that people think they can just order whatever treatment they want.

Public Service Announcement

Parents of the world:  taking your child to the emergency room (or urgent care, or primary doctor) for a viral infection does not magically cure that infection.  Your child will likely still have symptoms, including fever, for several days.  There is no need to bring your child to the ER every day until they admit you.  Let your kid rest, give plenty of liquids and Tylenol as instructed.  Thanks.

Hospital floors

Every day, I see either someone letting their baby crawl around on the hospital floor or letting their kid run barefoot in the halls.  You can't say anything to these parents without eliciting an angry, defensive response.

This really grosses me out.  Hospital floors are covered in millions upon millions of disease-causing germs, tracked all over from various rooms.  These germs, while together on the floors, share mechanisms for resisting antibiotics and evading the immune system like suburban housewives trading recipes. ("You simply must tell me how you manage not to be killed by antibiotics!"  "Of course!  But only if you tell me how you manage to fool those immune cells so neatly!")  Hospital staff don't observe the 5-second rule.  If a piece of food falls below knee height, it's done.

If that weren't enough, hospital personnel clean those floors with very harsh chemicals in an attempt to keep the population down (yeah, right.  Hospital germs would survive a disaster that killed all the cockroaches.). No eco-friendly, non-toxic stuff here.  And it isn't rinsed off the floors, either.  The longer it stays there, the longer it takes the population of germs to rebound.

So, a baby who crawls on that floor (then puts her hand in her mouth!! Ewwwww!!) is likely to either catch a horrible disease or be poisoned by chemical residue.  Or both.  Keep your kids off the bare floor!

Bad days

Most doctors and nurses love what they do, and love the human interaction involved.  However, some days we are just not feeling warm and fuzzy.  Maybe there are problems at home.  Maybe the ER woke us up at 2 am to ask if we thought it was safe to discharge the asthmatic who cleared after one treatment (yes, it happened to me).  Maybe the weather is crappy.  Whatever the reason, some days we just aren't chipper.  We still do our best for the patients, we just are far more...businesslike about it. Oh well.

If you don't trust doctors...

I get that some parents don't trust the medical profession.  I get that they think medications are poison.  I get that they think doctors care about money more than patients.  I get that they think nature is better.  What I don't get is why they bring their kids to the hospital, then refuse to let us do anything!  Why?!?

The Not-So-Affordable Care Act

We were assured, when the ACA was passed, that all Americans would have affordable insurance that would cover their medical costs.  That, apparently, is not true:

http://www.nbcnews.com/health/some-say-obamacares-affordable-coverage-isnt-affordable-them-4B11241833

Not only will some people have to pay out of pocket and wait for the subsidies, there's another sneaky little problem.  When the government is calculating whether the insurance your employer offers is "affordable,"  they look at what it costs just to cover you-even if you have a family to cover.  They don't look at what it costs to cover your family.  You may be able to afford coverage for yourself-but not for your family.  Don't count on getting affordable coverage if you are in the middle class.

Some of you may be thinking, Doc Rugrat's in the medical field; I bet Doc has good insurance.  And you're right.  But not all of my family and friends are that lucky.  And if I have family and friends who are in trouble, they can't be alone.  Unfortunately, even if the ACA were reversed right now, it's too late.  Companies that raised their premiums aren't going to lower them again.  We must find a way out of this mess.

Not clear on the team concept

Vanderbilt University hospital is apparently cutting its housekeeping staff and will have the nurses do much of the cleaning.  Great.  When I need a nurse to push drugs in a code, I don't want to have to look for one who isn't suited out, mopping the bathroom after the last diarrhea patient.

http://emergency-room-nurse.blogspot.com/2013/09/vanderbilt-university-medical-center.html

Sometimes the PARENT is the problem.

The kid is just fine with getting the shot, IV, whatever-until the parent goes apeshit with "oh, baby, it won't hurt, you'll be just fine, I'm right here, it'll be okay, it'll be over soon" and so on and so forth.  Then the kid bursts into tears, terrified.
THANKS, MOM!

Back to school time

It's that time of year when I am soooooo glad I don't have an outpatient practice.  All the parents who haven't bothered scheduling their kids' back to school physicals are frantically calling, and they don't understand why they can't get in immediately.

But all is not wonderful on the inpatient side, either.  The little dears who can't bear to go back to school are showing up in the ER complaining of abdominal pain.  They put on award-winning performances that get them admitted to the hospital after the million-dollar workup.

Once school starts, the kids who have kept their germs to themselves all summer start sharing generously with their classmates, and we start seeing the fall viral surge.

Oh well.  The pediatrician summer vacation is over.

The little "angels"

Whenever you see a kid on TV with a chronic illness-whether it is a real kid in a fundraising ad or a fictional character in a show-that kid is portrayed as being a sweet, brave soul, enduring medical torture with no complaints at all.  A few of them really are that way.  But, dear readers (if any of you exist), please let go of that mental picture.  Nothing about chronic illness automatically makes a child into a saint.
How a kid responds to chronic illness depends on the kid's underlying personality as well as what kind of parenting he gets.  Some parents spoil their sick kids rotten to "make up for" the illness; those kids are just pure evil for health care professionals to deal with.  Some are just scared of painful procedures, and who can blame them?  But the uncomplaining ones are rare.