‘doctor patient relationship’

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Ode To My Medical Assistant

I feel really connected to my medical assistant at clinic. The most incredible thing about her is she just “gets it.” She gets the pace of parenthood, the pace necessary to keep patient care moving in clinic, and the pace of my patient–even the very little ones and the big ones. She’s compassionate. She’s invested in being kind. She really treats children like children. When, for example, she doesn’t trust her gut on how a child is completing their screening vision exam, she’ll wait until end of the visit and repeat it. She’ll switch out letters for pictures, she’ll grab stickers to incentivize. This week, she was solving problems before I even noticed they were slowing us down.

She remembers patients like I do. The details, some health related, and some not. Glittery shoes, a nickname, a chronic ear infection, a mother’s need for extra time, a worry that a parent repeats. She says things like, “Did you hear about Angela’s CT at Children’s”” randomly on a Thursday two weeks after we last saw Angela.

She worries like a mom. She performs like a professional. She calls children by their name.

Not everyone in health care delivery is invested in what matters most. Unfortunately, it can be very easy to lose sight of patients in health care, however bizarre and inane that sounds. And so it’s an utter privilege to work with my MA. But more, it’s just so nice to have such an incredible partner. It’s, of course, teams of people that care for patients, not just doctors and the nurses you see. But teams of receptionists, labs techs, schedulers, assistants, insurers, leadership, specialists, nurses, generalists, and so many more.

Teams are good. But sincere, tactile partnerships change everything. Sometimes I feel very alone in my work–right now thanks to my MA, I don’t. To you, Katie, I say thank you so much for making 2011 far better and for all of the hope you bring to 2012…

5 Things I Say (In Clinic)

Five things I say in Clinic (in no particular order). After reading this, you’ll be all set for Family Feud when the category is Things Pediatricians Say.

Number One: I’m so sorry you’ve been waiting for me.

The reason is often varied. I’ve not been picking my nose or even doing something as productive as blogging. Usually I’m running behind because a patient or two arrived tardy for check-in or I’ve had to return a call to a doctor at the hospital or a family needed more time for an urgent health concern or a patient scheduled an appointment to talk about one thing (say a medication refill) and then wants to talk about three things like starting birth control or their struggle with obesity or a new challenge at school or a rash or because I needed to “double book” a sick infant who needs urgent care. The reasons are unpredictable, clearly, and I hate to make anyone wait, but I also hate to have families leave without comprehensive care. I work my tail off (as do my magical medical assistants) to stay on time, yet inevitably I am set up to fail. It’s an unusual doctor who never runs even a minute behind in a general pediatric practice. I sincerely hate to have people wait for me, as it’s a huge added stress for us all. Starting all visits with an apology makes for a terrible day. So next time you find yourself stuck in some waiting room with your toddler (+/- your 3 other children) and you’re going bananas, know that when your child needs the extra time or attention, they’ll get it, too. And if they never do—lucky you. Read full post »

Pediatricians’ Conditional Comfort With Alternative Vaccine Schedules

I had coffee with Dr Doug Opel last week to discuss his study about pediatricians and alternative vaccine schedules that published today. I learned a lot while we spoke. There is great wisdom in what he said (below in the interview & on video) that extends far past what he learned in the study.

Dr Opel is one of those genuinely authentic, kind people. The kind of person you meet and wonder, gosh if only I could be a fly on the wall when he’s making decisions for his kids or decisions for his life or decisions for his patients–I’d be so much better off. Not just because I’d see the answer, but because I’d have a front row seat while he asked the questions. He’s just remarkably thoughtful so there is no wonder this study illuminated some helpful observations.

Dr Opel and his colleagues conducted a survey of WA State pediatricians to find out how often they were being asked about alternative vaccine schedules and how doctors felt about it. Seventy-seven percent of pediatricians reported they are regularly being asked to use an alternative vaccine schedule. And in general, the majority of pediatricians (61%) are comfortable with alternative schedules but only for particular vaccines. Meaning that although pediatricians are okay with parents’ request to delay some vaccines (Hepatitis B vaccine or Polio) they are not comfortable waiting on others (DTaP, Hib, or PCV). The reason, Dr Opel suggests, is that pediatricians are unwilling to leave kids unprotected for potentially devastating diseases that still circulate in our communities.

In this interview, Dr Opel lends insight to the culture of concern about vaccine safety, how the changing health care environment has shaped how we ask questions in the exam room, and how the concern about autism and vaccines is simply emblematic of concerns about vaccine safety in general. Read full post »

Pediatricians Who Refuse Families Who Don’t Immunize

I just responded to a New York Times “Armchair Ethicist” chat about pediatricians who refuse patients who don’t fully immunize. I realized my comment on their site belongs here on the blog. (my comment is number 79 but also copied below).

What do you think about pediatricians who refuse patients who don’t follow the AAP schedule? Do you disagree with me? Would you be more comfortable seeing a pediatrician who refused those families who chose not to immunize to protect your children? Have you, or someone you know, ever been kicked out of a pediatrician’s practice?

I’m a pediatrician (w a master’s degree in bioethics) and mother to 2. I will always keep my practice open to vaccine-hesitant families. However, the waiting room risk (unimmunized kids & risk to vulnerable populations–ie infants, those too young for vaccines, and immunocompromised children) is a good one and the only compelling reason to close to patients who refuse immunizations in my opinion.

But it’s not a good enough reason for me to send families away who have questions and hesitations about the AAP/CDC schedule. All children deserve a pediatrician versed in immunization benefit/risk & deserve an expert in conversation w their parents to foster insight & understanding. Frankly, if waiting room risk is the concern, there are ways to create separate waiting rooms for kids “up to date” and kids who are not.

Great thing is, only about 10% of families use alternative vaccine schedules. In a recent Pediatrics article, only 2% of families who used alternative schedules refused all vaccine altogether. So although this is a large issue in pediatrics and parenting, the majority of families do vaccinate on time or nearly on time. I don’t want to lose sight of that.

I practice in WA State. We lead the nation in exemptions for vaccines (over 10% of kids w exemptions vs only 2% nationally) and have recently put into place a law that requires families to consult with a health care provider prior to an exemption. It was designed to avoid exemptions out of convenience. This hopefully opens up the opportunities for discussions with parents & pediatricians!

We all want the same thing: healthy children, healthy communities. Fostering conversation and diminishing a context of “war” or opposition about immunizations is an important step. In my experience, most parents end up immunizing their children over time even when they start out as refusers. The group of full refusers is fairly small. So allowing all kids into my practice feels like a great opportunity.

Why Doctors Fail To Change Behavior

Earlier this week I wrote a post about raising heart healthy children. The data summarized in that post may be the most important data I discuss all year when you consider that heart disease kills more of us than anything else. Thing is, I’m not surprised many of you haven’t read it. I expected it.

It’s just so flipping hard to read, or have any interest, or take advice about health when the advice or data requires us to make big changes. Or when the advice (regardless if we trust it or not) seems intuitive and self-evident. Things like eating less, restricting salt, or exercising more don’t sound so new. Those are things we already know we should do, but we often just can’t find a way to implement change in our totally overwhelming and busy lives. Big changes regarding how much we exercise, what we eat, and how we model behavior for our children seem daunting, overwhelming, and somewhat paternalistic. I also think it’s uninspiring to read about preventing heart disease in our kids because it feels so far off (thinking of our child dying of a heart attack or stroke doesn’t really compute) and really, we often can’t see heart disease. Heart disease walks around us silently.

That’s where we physicians fail, I think. There is convincing data about preventative health care that urges us to help get our patients to change behaviors that cause them suffering and ultimately threaten their life. But we fail to convince our patients to make changes because we simply don’t make it relevant enough. Or easy enough. Or we’re not convincing because we don’t demonstrate that we follow our own advice. Many docs are constantly trying to figure out what works best. See this tweet from Dr Pourmassina, an internal medicine physician in Seattle.

I think about ways to improve our translation of research for our patients all the time. And I think telling stories really helps. But I didn’t begin that post about heart disease with a story. Although there are many.

Last weekend for example, I set out to exercise every single day (without fail) for 30 days. I haven’t had time to prioritize exercise (let’s be honest: since F was born) over the last 5 years. And in my quest for 1 month of change, already I’ve failed. I made it only 3 days. And not for a lack of motivation; I love to run. Read full post »

Speaking Up In The Exam Room

I was in a cab yesterday afternoon. I’m at another conference this week and as I made my way to San Diego, I had to count on many people to keep me safe. From the pilot to the air traffic controller to the cab driver. We do this all of the time, of course–step into a moving vehicle, sit down, inform another person where we’d like to go and then just trust. Trust that they know how to drive, that they’ll take care of us, that they’ll do their best to remain aware, responsive, and agile in the face of unexpected events. We trust that they’ll keep us alive and return us to our children. We do this at the clinic and at the hospital, too.

As I sat in the back of the car, I noticed a sticker on the window describing the bill of rights for passengers for San Diego Airport cabs. The list detailed things I was due: a safe car, a working seat belt, a music-free ride for example. And the kicker, a driver who doesn’t talk on the cell phone.

Read full post »

Monday Phone Call

I called my doctor today. Well, I called her office, of course. I needed an appointment to see her this week. First available appointment was next Friday (11 days). “Okay,” I  thought, settling, “That will do.”

But forgive me, let me rewind. The receptionist asked me for my medical record number. Before my name. It was the first question he had for me upon answering the call. When I didn’t have it, he started with my first and last name along with my birth date. We found my record without trouble. But he noticed it had been 5 years since I’d been in. This brought trouble.

I said, “I’ve been having babies, so my OB has been doing my preventative care,” to which he said nothing. “Well,” he said, “I’ll have to e-mail the doctor. She’ll need to agree to see you since it’s been so long.” It gets worse: “It’s going to be another week until we know,” he said. “She’s on Spring Break this week, so it may not be until next week that you hear if you can get in. Unless she is checking e-mail while away.”

Oh, I hope she’s not checking e-mail on Spring Break. Really. But, Read full post »

Play

Recently, I started asking a standard question, exactly the same way, to children during their 3 to 10 year old check-ups. This wasn’t premeditated. Like all physicians, I go through phases of what I ask kids to elicit their experiences and beliefs, listen to their language and observe their development. I learn a lot about my patients from what they choose to answer. Both in their receptive language skills (how they understand me) and their expressive skills (how they speak–fluidly, articulately, with sentences) to their cognition (how they understand concepts and theories). No one talks as much when in the exam room as they do at home. Pediatricians know this (of course!), but these questions are a great way to learn a lot about a child’s wellness and get to know my patients. It’s also the part of the day I enjoy the most.

But when I started asking a recent question something became utterly clear. I’d say,

“What do you like to do at home?”

I expected the usual suspects. Things like, “Watch TV,” “Play the DS,”, or “Play with princesses or doll houses.” Not that I expected stereotypes, I just expected specifics. But instead, there has been a uniform, single-word response. Breath-taking. These children are all saying the exact same thing.

“Play.”

One word. Read full post »

An Amalgam In The Exam Room

This post is an amalgam. Not the kind that fits in your back molar, but the kind that exists in my head. I’m trusting you have this type of overlapping-quilt-like-consuming-idea-thread that resides in your head at times and ultimately becomes thematic. How one event in life opens a new window into others and then suddenly there is sense and commonality in different spaces and experiences. You know what I mean? Evolving wisdom or simply experience, I don’t know. But I mean how something persists in your every-moment and helps you define meaning  with each new space and time. I’ll explain…

On Monday, a blog post of mine from last summer was published on Dr Kevin Pho’s blog, KevinMD. The post detailed my mom finishing her chemo and 5 words that her oncologist spoke one sunny afternoon: “You’re the picture of health.” The post is about the power of a physician’s words and how words spoken in the exam room linger in our life. In this post, I spoke about words we hear as patients (and caregivers) and how it’s essential that doctors detail wellness when they see it (rather than always focusing on illness). But reading the post again brought me back to last summer. More than once this week (let’s be honest, maybe like 6 times) I’d think about the post and well-up with tears. Maybe it’s the reality that we all face mortality or that I’ve been ushered into a new moment with my mom in her current remission where I am not filled with worry every day. Or maybe it brought me back to the emotion that was in the exam room that day, too. The same emotion I’ve typically divorced myself from. But,

It got me thinking, how was it I was starting a blog, helping my mom through chemo, moving to a new home, and caring for two little boys while caring for a panel of patients during that time? Why wasn’t I in a puddle of tears? Well…see…we do this. Parents (and children) do this ALL THE TIME. They muster incredible courage. Parents face fears. They exceed expectations and bust through boundaries for their children. For example, in the exam room, I tell parents we’re admitting their child to the hospital and then they listen, they thank me, they discuss.  They rise up to what is asked of them without their heart falling out of their chest and landing on the floor. They endure. They “keep it together,” they advocate. They share. Yes, they break down sometimes, too. Yes, they tremble. But they always do what they need to. They endure.

Which got me thinking, we really can be the balogne in the generational sandwich. Read full post »

500 Words on a $5M Fine

No photo for this post. You can imagine why.

I’m a little stunned by the news that a politician in Florida is trying to stifle pediatricians from asking questions about guns in the home. My reaction is utterly predictable. Should I YELL IT or write it down or leave it up to your genius (and imagination)?

(silence)

The Skinny on the Florida Proposal:

  • Florida Rep. Jason Brodeur said “he has heard about a number of cases in which doctors asked about guns. He thinks the topic should be off-limits.”
  • Brodeur says he’s concerned about doctors asking patients about guns in the home. He’s concerned that information could get into the hands of the government or insurance companies.
  • Under the proposed legislation, a doctor could face a fine of up to $5 million or be sent to prison for up to five years for asking about guns in the home.

The idea of blocking the right to advocate for children is preposterous. Clearly pediatricians don’t like censorship, particularly when it gets in the way of protecting the lives of children. We don’t even like censorship from our patients; we like it when adolescents tell us the truth about having sex, doing drugs, and self-tattooing. We like it when parents tell us what truly keeps them up at night. Really. Transparency and a lack of censorship is an imperative ingredient in the doctor-patient relationship. The exam room is a space and place where you’re not faulted for telling the truth. Read full post »