Do after hours nurse call centers send an unacceptable number of kids to the emergency department?

May 22, 2019  |  General  |  No Comments

A large number of pediatric practices these days use after-hours call centers for parents who have questions about a sick child. I’ve been looking around to find some data about how common this is, but my sense is that the majority of pediatricians use them. There is no question these call centers make live easier for the doctor; having somebody screen the calls, answer easy questions, and only call you for important issues is a great boon. But that boon comes at a cost: the people staffing the call centers are not doctors. They are often experienced nurses, but that is not the same thing. So deciding what is important and what can wait can be a problem.

The call centers generally use predetermined protocols drawn up by experts to help guide decision-making. This is a good way to ensure consistent, quality advice. But not every child fits the protocol, and a set of guidelines is not a substitute for actual clinical experience. Really, these days a savvy parent can get almost as much useful guidance from consulting Dr. Google (or my latest book). A study presented at a meeting of the American Academy of Pediatrics examines another question: do these call centers send too many children to the emergency department?

My assumption would be that they do. After all, they are hard-wired to do so. If you call one, the person giving you advice not only is not a doctor, they do not know your child. Also, the decision-making protocols they use necessarily err on the safe side. So if there is any doubt about what to do they will advise you to take your child to the emergency department even though your child’s doctor often might not do that.

The study bears out this presumption. The investigators, from Children’s National Medical Center in Washington, D.C., examined the records of 220 children for whom the call center advised parents to take their child to the emergency department. They used a panel of evaluators to see if the visit to the ED was appropriate. They found that, for a third of the children, they could have safely stayed home.

After-hours call centers have made doctors’ lives less hectic, and I’m not suggesting we do away with them. They give thousands of parents useful advice. Plus, what we don’t know is if even more of those 220 children would have ended up in the ED if the call center didn’t exist: who knows, perhaps they steered a significant fraction of children away from an inconvenient and expensive ED visit. However, in my own anecdotal experience the call centers do increase ED use. I have had many parents tell me, after I’ve seen their child in the ED, that the only reason they came was that the call center told them to — that they were surprised by that advice and otherwise would have stayed home.

My own father was a small town pediatrician. He didn’t have an answering service. When parents wanted to ask about their sick child they just called him at our home. His phone number was in the directory just like everybody else’s. He didn’t have any sort of pager. If he wasn’t home, people called back or else called whatever number one of us kids or my mother told them where to call to find him. Those were simpler times, and not necessarily better ones. Now we have call centers, and we need to figure out how best to use them.

I’d be interested in any experiences, good or bad, that parents have had with after-hours call centers. Were they helpful? Were they a problem?

Asthma action plans actually help keep kids out of the hospital

May 15, 2019  |  General  |  No Comments

Asthma is a common childhood condition. Estimates are that around 8% of all children have it. The incidence had been steadily increasing for many years, but some recent data suggest the burden of the disease in children may have leveled off over the past couple of years. That’s encouraging, but the number of children with asthma is still huge. The peak age group is 5 to 14. The best way to think of asthma is that of an exaggerated reaction of the small airways in the lungs to common irritants, making them constrict and reduce airflow. These include viral infections, environmental triggers, and poorly understood things intrinsic to the individual. There is a strong familial tendency to developing asthma. Additionally, some things predispose to it, including sedentary lifestyle and obesity.

Over the past decade there has been an increasing push to recognize that asthma is multifactorial and that early interventions, things parents can do at home if their child’s symptoms worsen, can head off acute deteriorations that lead to hospitalization. The standard now is that every child with asthma have an action plan for the family to follow. The plans are designed to be specific to the child and concrete in their instructions about what to do. They typically divide into three, color-coded sections. Here’s an example of what they look like.

There is some research showing how useful these plans can be. The investigators looked at 3,510 children with asthma treated over the years at Primary Children’s Hospital in Utah. The notion was to see if increased compliance with asthma control measures by the family would reduce the number of hospital admissions. That turned out to be the case, significantly so. Interestingly, one of the biggest problems for the research project was to get physicians to accept and go along with the best current evidence-based information about how to manage asthma. I’m actually not surprised by this. Asthma management has changed over the years and current best practice is not what I was taught years ago. Things change, but many physicians don’t.

The key for any parent who has a child with asthma is to have a clear understanding of exactly what to do if your child has worse breathing problems. Many visits to the hospital could be headed off if all parents had such a plan, as well as a resource person to call if the plan is not working.

A concerning case from Minnesota: physicians may be held liable for “curbside consults.” But does the case really indicate that?

May 12, 2019  |  General  |  No Comments

“In a case that could have wide-reaching implications for medical practice in Minnesota, the Minnesota Supreme Court issued a ruling on April 17 in the case of Warren v. Dinter holding that the existence of a physician-patient relationship is not a prerequisite for a medical malpractice action. Rather, a person may sue a physician for malpractice – even if that person was not a patient of the physician – if the harm suffered by the person was a “reasonably foreseeable consequence” of the physician’s actions.” 

The decision in question concerned a patient who came to an outpatient facility and was evaluated by a nurse-practitioner, who thought the patient might need to be admitted to the hospital. She called the hospitalist (today’s term for physicians who specialize in only caring for hospitalized patients) at the hospital that practice generally used to discuss it and the hospitalist physician did not recommend hospitalization. The nurse practitioner accepted this recommendation and sent the patient home. Note that the hospitalist neither examined the patient nor had access to the patient’s medical record; he was not even physically present in the building. The patient later died from severe infection and the patient’s family sued both the nurse practitioner AND the hospitalist.

Physicians get what are often called “curbside consults” all the time. I may call a subspecialist at the nearby University Hospital to ask some questions about a patient and get advice about what I should do. I’m ultimately responsible, of course, for whatever I do or don’t do but I may just need some advice or sometimes just another person to bounce ideas off. Similarly, physicians in facilities around the region who want to transfer a child to my PICU always call me for advice about what to do before the child gets to me — it’s totally routine. Good medical practice absolutely needs these sorts of interactions to give good care. The university system I deal with, like many such facilities, even has a special phone number for me to call to get quick access for expert advice. Traditionally, in a legal sense the physician providing the curbside consult is not liable for the advice because he or she doesn’t have a formal relationship with the patient; they have never seen the patient, never seen the actual medical records, and never examined the patient. At first glance the decision from Minnesota has some ominous implications for this universal medical practice. But does it really?

Of course, as with most things, the devil is in the details, especially when considering how generalizable this court decision is to usual practice. I am not a lawyer, of course, but I did look at the actual decision here. The first lines of the decision reads: “A physician-patient relationship is not a necessary element of a claim for professional negligence. A physician owes a duty of care to a third party when the physician acts in a professional capacity and it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That, to me, is a bit chilling. This is because the physician giving the advice is giving it based upon what he is told, and what he is told may be incorrect or incomplete.

It is important to point out that the Minnesota Supreme Court did not find for the patient. The court ruled only that the hospitalist physician could be sued and remanded the case back to the lower court. The language also stated the hospitalist “denied” the hospital admission. That’s a different thing than recommending against it. The decision also states the physician must “breach the standard of care.” Those are key details, I think, in assessing what this decision means. In my own practice, I never outright deny an admission if someone calls me asking for one. I may suggest the child not come to the PICU, but I facilitate admission to the appropriate hospital unit. If my PICU is full so I don’t have a bed for the patient, I help the calling physician find one at another facility. But if I am accepting a patient I do give advice about what to do, and that advice is based upon what a person not trained in pediatric critical care is telling me over the phone. It is not uncommon for whatever I’m told to be wrong, or at least incomplete. I would hope that would offer me some legal defense if ultimately necessary.

The court did go into what it called standard curbside consultations, and described why this particular interaction was not such: “Our decision today should not be misinterpreted as being about informal advice from one medical professional to another. This case is about a formal medical decision — whether a patient would have access to hospital care—made by a hospital employee pursuant to hospital protocol.” The court also provided some examples of how this expanded definition of professional duty has been applied in the past to both medical and legal practice. Also, a conversation between a nurse practitioner and a physician is intrinsically not a a conversation between professional equals. I think this carried some weight with the court.

The bottom line for me is that this decision is somewhat concerning, although much less so if narrowly applied. Anybody deeply concerned should read the actual decision linked above.

Parental-child interaction in reading to toddlers differs between electronic and print books

May 8, 2019  |  General  |  No Comments

Over the past decade child development experts have produced an increasingly large body of evidence on the dangers of too much screen time for children, especially preschoolers. These include increased risk of attention deficit hyperactivity disorder (ADHD) and other learning problems. The consensus opinion is that the rapidly changing images, coupled with the passive nature of the experience, are not good for the developing brain, and the brain continues to develop well into late childhood. This is especially the case for preschoolers. A potential problem is when parents use the screen, whether a television or computer screen, as a sort of babysitter. Now there is nothing wrong with this for short periods, but the American Academy of Pediatrics has offered guidelines on how much is too much. It’s a good resource. The AAP and child development experts particularly recommend reading books to toddlers as a way of fostering the back-and-forth interactions that promote emotional and cognitive development. But now, of course, we have a hybrid — the book on a screen, the ebook. Many people I know do their reading these days almost exclusively on the screen. My own books sell more electronic versions than paper ones. What do we know about reading to your child on an ebook? Is the experience the same as an actual physical book?

Some previous research suggested when preschoolers read electronic books with parents, parents offer less dialogue, and talk is often focused on the technology rather than the book contents. What about other interactions besides talking, the more subtle things? A recent study in the journal Pediatrics offers some information about this. The authors conducted a videotaped study of 37 parent-toddler pairs reading on the different book formats and observed what happened using some standardized criteria for shared positive affect and collaborative reading. They found that the pairs reading an ebook verbalized less to each other and collaborated less, meaning pausing and interacting with each other. These differences were statistically highly significant, with p values of < 0.001 for those of you who like statistics.

For myself, I don’t think these differences are necessarily intrinsic to the medium. It’s certainly possible to be as interactive with your child with an ebook as with a physical, paper one. But for whatever reason parents don’t do this. Perhaps it’s because our own interactions with computers and iPads are somewhat passive and self-centered, different than jointly with our child holding an open book in the lap. But whatever the reason, it gives evidence for the benefit of the well-worn and much loved copies of favorite children’s books we recall. Certainly my daughter’s dog-eared copy of Curious George was like that.

Febrile seizures associated with vaccinations are no different from those from other causes

May 3, 2019  |  General  |  No Comments

A seizure in response to a fever, called a febrile seizure, is an extremely common event in childhood. They affect 2–5% of children between 6 months and 5 years of age and have a peak incidence between 12 and 18 months of age. They generally occur after a rapid rise in temperature; it appears the rate of rise is more important than the actual temperature. Febrile seizures probably represent an age-dependent response of the immature brain to fever. They are more common in boys and in children with a family history of febrile seizures. Neurologists divide them into simple and complex: simple ones last less than 15 minutes, generally less than 5 minutes, and the child is back to normal in an hour; complex ones last longer than 15 minutes or occur several times in less than 24 hours. The overwhelming majority are simple febrile seizures and the child completely recovers. Generally no further testing is required to diagnose them and typically no therapy is needed because they stop so quickly. They can be scary, though, for parents who have never seen such a thing. A child who has one is at increased risk of having another before the age of five. You can read about them in detail here and here if you want to learn more.

Vaccinations can occasionally be associated with febrile seizures because a child may have a fever after receiving a vaccine. Some parents are concerned that this variety of febrile seizure could somehow be worse than one from another source of fever, such as an ear infection. This is a particular claim I often see on social media where vaccine denialists gather to promote their often wildly fallacious claims about vaccines. They often insist febrile seizures following vaccinations somehow injure the brain even though simple febrile seizures from other causes do not. There has never been any evidence in support of these false claims, and now there is new evidence refuting them. It appeared the most recent issue of Pediatrics, the journal of the American Academy of Pediatrics.

Investigators in Australia compared children experiencing their first febrile seizure following vaccination with those who had their precipitating fever from other sources. All children were otherwise completely normal. There were 1,022 children altogether, of which 6% had vaccination as a fever source. The median age of the children, 20 months, fits what we would expect. In sum, there were no differences observed between the two groups. In particular, there were no difference in the nature of the seizures, their duration, or the treatment and tests required. Children who had a fever with an infection were, unsurprisingly, more likely to be admitted to the hospital on account of their infection. Their conclusions are important:

This study confirms that vaccine-associated febrile seizures are clinically not any different from non-vaccine associated ones and should be managed the same way. Our findings can be used to counsel concerned parents that although some vaccines have a known associated risk of febrile seizures, clinical severity and outcomes of these are no different to those from another cause. This information helps support the recommendation to these patients and their families that additional required vaccinations can be administered in the future.

This study supports previous ones that have found the same thing. The advantage of this new one is that the Australian system allows very complete tracking of these children, correlation with vaccination records, and follow-up of how they did later.

How to deal with difficult doctors X: The poor examiner

March 8, 2019  |  General  |  No Comments

Here is another post from my book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor who I call “the poor examiner.” The point is that, as with my previous posts about difficult to deal with physicians, there are things you can do when you encounter one that can still allow you to get the best care possible under the circumstances.

It sounds difficult to believe, but some doctors are simply not good examiners of children. I do not mean that they were not properly trained or that they are incompetent; they simply are not smooth when performing an exam. You will virtually never find this quality in pediatricians or exclusively pediatric subspecialists, but you will occasionally meet physicians whose scope of practice spans the pediatric age spectrum but who are much more proficient in examining older patients than they are dealing with children.

Sometimes this problem is largely a social one; every parent knows it takes a special knack to put a toddler, older child, or adolescent at ease during a physical examination. Each of these developmental stages has its own particular nuances, and facility in examining children from infancy to young adulthood is something some doctors never really master. Even though a doctor’s examination may be effective in that she correctly identifies the problem, she may still make the child or the parents uncomfortable with how she does it.

If you and your child are dealing with a physician like this, your new knowledge that you obtained from this book of how doctors routinely examine children, the process itself, can help the situation. You can reassure your child about what is going on and what comes next, something the doctor ought to do but may forget, given her particular communication problem. You can help the doctor position your child for the examination, such as for a toddler’s ear check or a school-age child’s abdominal examination. In my experience, most physicians of this sort appreciate such parental assistance very much because they fully realize examining children, especially uncooperative children, is not their strong suit.

How to deal with difficult doctors IX: The avoider

March 2, 2019  |  General  |  No Comments

Here is another post from my book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor whom I call an avoider. The point is that, as with my previous posts about difficult to deal with physicians, there are things you can do when you encounter one that can still allow you to get the best care possible under the circumstances.

Most of us are, to some degree, procrastinators. We avoid or postpone doing unpleasant things. In this sense, physicians who are avoiders are no different from anyone else. For a doctor, however, avoiding things often leads to poor, or at least less than frank, communication with parents.

One kind of avoidance behavior is when the doctor avoids answering your questions. These doctors do not behave this way because they are poor listeners; they just find it uncomfortable to answer your questions. Often this doctor takes the oblique approach of not quite answering the question you asked, and instead rephrasing it into a question he would rather answer. He tends to talk around issues, especially those that are part of serious, unpleasant, or intractable medical problems. He also tends to use euphemisms for unpleasant things, commonly retreating into medical jargon because medical language seems more sanitized and neutral.

I have considerable professional experience with avoiders because my own subspecialty of critical care often presents parents and physicians with difficult choices, situations in which there are sometimes no good options, just less bad ones. Many times I have spoken with parents who, after an interview with a physician who is an avoider, must ask me what the doctor really meant to say. And that is the key to the avoiding-type of physician: he probably thinks he is doing what is best by filtering what he says and not speaking directly, but parents invariably want their questions answered as directly as possible. If you find yourself in an interview with a doctor like this, you really have no option except to press him for an explicit answer to the question you actually asked, not the one he chose to answer.

There is another variety of the avoiding physician encountered by parents whose child has ongoing medical problems. This is the doctor who just plain avoids them and their child. These are doctors who only reluctantly return your telephone calls or, if your child is admitted to the hospital, always seem to miss you when they come around to see your child in her room. This seems like odd behavior for a physician, but it is not rare. The reason for it is that the doctor procrastinates or even avoids conversations that he believes, for any number of reasons, will be difficult or uncomfortable either for you or for him. Of course, that is all the more reason to have the discussion. Nothing interferes more with a conversation than one of the parties not showing up to partake in it.

How to deal with difficult doctors VIII: The overly defensive physician

February 24, 2019  |  General  |  No Comments

Here is another post about difficult physicians from my book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor who is excessively defensive.

I divide this kind of communication blocker into two varieties: physician personality and physician mode of practice. The physician with a defensive personality is one who interprets questions from parents as questioning of her medical judgment. Unlike the supremely egotistical doctor, who is often sufficiently secure in her image of herself that she is magnanimous toward parents who ask questions, the overly defensive physician has the opposite sort of personality; she may be inwardly or outwardly unsure herself and often responds to parental questions in self-justifying ways that can border on the argumentative. Parents easily sense this attitude. For example, I have heard exchanges in which the parent feels a need to begin a question to the doctor with something like “I’m not questioning your medical judgment, but what about . . .”

Physicians with naturally defensive personalities probably had those tendencies reinforced in their medical training, since students and residents are often closely questioned, even roughly attacked, by superiors who believe this sort of hazing is a vital part of teaching young doctors. These kinds of teachers are becoming rarer, but there are still enough of them out there that students who fall into their clutches emerge from the experience with whatever defensive tendencies they already had greatly enhanced. Rather than welcoming parents’ questions as an important tool for two-way communication, they are more likely to feel threatened when a parent asks them probing or even quite innocent questions.

A bigger potential problem for parents with sick children is not the physician with a defensive personality but the physician who practices defensively. Medical testing, excessively and inappropriately used, can cause major problems and even place a child at significant risk. Physicians who practice defensively usually order too many tests, thinking that by doing so they are both helping the child and covering their own backsides. In fact, poorly justified, “shotgun” lab testing does neither of these things. Much has been written about how physicians defensively order too many tests because they worry about being sued for malpractice if they miss something. This may be true to some extent. However, my own observation is that physicians who practice this way would probably do so even if the threat of malpractice litigation did not exist, since defensive medical practice is to a great extent a function of the physician’s personality.

Doctors who are excessively defensive in their use of medical tests also tend to use subspecialty consultations in the same way. Very sick children with complicated problems often need the knowledge and skills of experts. But as a subspecialist myself, I know that some doctors call in the subspecialists largely to spread the responsibility more than anything else, a behavior we call “loading the boat.” If you find an overly defensive doctor evaluating your child, you may find that you need to take an active role in questioning the appropriateness of multiple tests and consultations with subspecialists. And remember—subspecialists often want even more tests and procedures, potentially adding still more unneeded complexity to your child’s situation.

How to deal with difficult doctors VII: The egotist

February 23, 2019  |  General  |  No Comments

Here is the next is a series of posts about strategies you can use when you encounter a difficult physician. It’s taken from my book, How to Talk to Your Child’s Doctor. This one concerns what I call the egotist.

Egotism is a common trait among doctors, although most of us keep it under adequate control when dealing with patients. The ideal doctor-parent encounter has been described as a collaboration among equals, each of which brings expertise to the exchange; the doctor knows medicine, the parent knows the child. This is the ideal, although sometimes the reality falls short of it. The way our medical system is now structured gives more power and influence to the doctor side of the relationship than the patient side. Things were not always this way; a century ago a surplus of doctors with treatments of doubtful usefulness scrambled to attract patients. These days, however, physicians have many more therapies that actually work, plus the benefit of an enormous medical establishment behind them. So now doctors are usually the ones deciding who gets what treatment, which is on balance a good thing. In spite of that fact, good, experienced doctors will do their best to use their power over patients lightly, always inviting parents and patients to share in the authority.

Physician egotism can get in the way of good communication in several ways. A simple manifestation is the tug-of-war over whose time is more valuable, the doctor’s or the parents’. A good example of this conflict is the doctor who schedules far more patient appointments than he can accommodate in a day, then seems unaware of how keeping a parent waiting for hours can poison the atmosphere even before the evaluation has even begun. Parents usually understand long waits when they take their child to the doctor for an unanticipated acute problem. If the waiting room is full of children just like theirs, there is little the doctor can do except see them each in turn. But the subspecialist who packs his waiting room with too many scheduled patients is proclaiming, in effect, that his time is far more valuable than that of parents, who often must take off a full day’s work to bring their child to see him.

The egotistical doctor is one who tends to forget that the patient is the center of everything, the reason the parents are there in the first place. He forgets that the encounter is about the child, not the doctor. This attitude can show itself in a persistent tendency to turn the subject of the conversation away from the child and toward the doctor. The result may be harmless, as when a garrulous doctor is genuinely trying to relax the parents and their child with a friendly conversation about other things, or it may be more toxic, as when a doctor constantly talks about himself and what he does. The latter can be particularly trying to parents who have waited a long time to see the doctor, only to find their brief time with him taken up by extraneous chatter.

Although it can be annoying to parents, excessive egotism in your child’s doctor is generally a minor issue in the big picture of getting your child the evaluation she needs. I say this because, although there are exceptions to everything, for the large majority of doctors I have met who are more egotistical than the average, their self-centeredness does not get in the way of their medical skills. In fact, some subspecialties, such as high-risk surgery, almost require the physician to have a huge ego if he is to perform such surgeries effectively .

So it is largely a matter of the personal taste of the parents. If you find yourself irritated when talking with an excessively egotistical doctor, and if you think this is interfering with his proper evaluation of your child, the best thing to do is to be persistent in turning the conversation back to your child at every opportunity. Of course, if you are really irritated by his manner or the way he treats you, do your best not to see him again.

How to deal with difficult doctors VI: The judge

February 22, 2019  |  General  |  No Comments

Here is another post taken from my book, How to Talk to Your Child’s Doctor. This one concerns what I call the judge.

All physicians naturally make judgments regarding the parents they are interviewing. For example, we assess how accurate and plausible their history is. We try to decide if they are telling us the whole story and, if not, if they are inadvertently or deliberately holding something back from us for whatever reason. All experienced physicians do this. What we rarely do, however, is judge the parents’ worth as people, as individuals apart from their children. There are exceptions to this, like all blanket statements in medicine, but we cannot do a good job abiding by the important ethical principle of equal care for all children if we categorize parents as good or bad. After all, children do not choose their parents.

The inappropriately judging physician runs the risk of allowing his opinion of a child’s parents to get in the way of his taking proper care of the child. His judgments might be condemning or laudatory; either type can cause problems because they lead to assumptions that may not be correct. Physicians should be especially vigilant about the dangers of inappropriate judging when there are social differences between them and parents, such as ethnicity or language. All humans have the capacity to be good parents. I have seen convicted felons who are better parents in comparison to people who are social pillars of their communities.

Interestingly, judging physicians sometimes err by overvaluing the position of the parents. One sees this occasionally when one or both parents are medical professionals. There is a real risk for miscommunication if the evaluating doctor assumes that parents’ medical or nursing knowledge means they are perfect observers and historians. When their children are ill, parents who are doctors or nurses are parents first and need to be treated that way.

Unfortunately, there is not much advice I can offer if you believe that a physician’s judgment of you as a person is interfering with his assessment and management of your child’s medical problems. As with other potential communication problems between parents and doctors, confrontation is rarely a good strategy, since a physician guilty of this communication problem is unlikely to admit it or even recognize it. My best advice is, armed with what you have learned in the previous chapters, to do the best you can to ensure that your child’s evaluation—the history, physical examination, and laboratory tests—is as thorough as it needs to be, and that the doctor, whatever you think of him, explains things completely.