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An unusual ‘retirement’ option
Whether “retirement” is withdrawing from one’s occupation or from an active working life, it is of utmost importance to not let one’s mind degenerate. Some individuals move on to gathering new intellectual skills by attending new educational courses or meetings, some travel, some become semiprofessional golfers or fishermen, and some find other forms of personal extension. I now serve to develop cost-saving medical programs for county jails in the state of Texas while attempting to improve the overall quality of inmate care.
Initially I was a pediatrician in Houston with special training in allergy and immunology, but because of a medical problem I was forced to abandon my first love – primary pediatrics. My move to a small town at the age of 40 required me to reevaluate my professional life, and I opted to provide care only in my allergy and immunology specialty.
However, living in a small town is different from life in a metropolis, and it was not uncommon for doctors to be asked to assist the community. A number of years ago, our county judge asked if I would help evaluate why our county jail was spending so much money. After several attempts to refuse, I eventually did evaluate the program there, and was flabbergasted by how much money was being wasted. I made some rather simple suggestions as how to correct the problem, but when no primary care doctor stepped forward to implement the changes and run the jail medical program, I became its medical director. When we saved $120,000 the first year, even I was astounded.
While I continued to run my private practice, I did accept other small community’s offers to look into their county jails’ programs. I found that their problems in cost control and quality of health care mirrored those I found in the first jail, and they were easily solvable if the county judge and the local sheriff wanted solutions. I also found that politics makes strange bedfellows, as the saying goes, and often the obvious changes were met with obstruction in one form or another. Nonetheless, I found that I could serve these communities in addition to my individual patients. When it was time for retirement, I continued to have a real desire to make the towns around which I lived and my own community more livable. So
In most things, I found that the same business philosophy and personal medical approach I learned in my pediatrics training and as a private practitioner applied to the jail system. Let me mention some specifics. Using generic medicines was less expensive than using brand names. The diagnoses which patients claimed when they entered jail might or might not be correct, so reevaluating the diagnosis and treatment was appropriate as soon as possible. Hospital and ED visits should be limited to patients’ medically requiring them rather than using the ED as a screening tool.
But I did come to understand that medical care in the county jail is different from medical care outside an incarcerated facility in that sometimes the prisoners had their own reasons for seeking medical care. This was complicated by the fact that often there were critically ill patients presenting to county jails. So carefully established criteria and protocols were an absolute necessity to save lives.
Let me expand on the topic of seeking medical care by the inmate-patients. A relatively small number of these individuals required immediate emergency treatment, without which they could not do well: The diabetic who was not taking his insulin, the out-of-control paranoid schizophrenic who decided he was cured and therefore was unattended, the alcoholic or drug addict who would develop delirium tremens if medications were stopped abruptly. These people had to be identified as quickly as possible and correctly treated. Confounding the problem was the fact that many, and I repeat many, individuals try to use the medical route to manipulate their incarceration environment. I called this the B problem: beds, blankets, barter, buzz, better food, and be out of here. They might claim an illness existed, and often they might believe it did.
A related situation might exist when individuals would demand psychiatric and pain medications, often in large quantities, when they in fact had not taken them for some time in the outside world. Often these patients were addicts, and of course this could create an entire other relationship with the medical team. A third example would be the claim of hypoglycemia so that the prisoner would receive more frequent meals.
One might think that as a pediatrician I was ill prepared to treat adults, and in fact, there was much review of the general medical care needed when I began this program. However, the internists and family physicians in town were glad to assist me whenever I encountered a difficult patient. When hospitalizations were required, the inpatient always was covered by one of the internists on hospital staff. Quite frankly, the doctors seemed pleased to not be dealing with this group of individuals as much as they had in the past.
On a slightly different note, skills honed during my pediatric career were extremely valuable. Children, particularly young children, do not verbally communicate with their parents or their doctor particularly well, so pediatricians are well trained in the skill of observation. The patient who claims a guard hurt his shoulder so badly during an altercation that he cannot move it is found out when he easily whips his arms over his head when asked to remove his shirt. It is not uncommon for an individual to demand antidepressant medications from the medical staff, but when evaluated more thoroughly and for a longer period of time, the patient ends up laughing, even denying any suicidal ideation or any other sign of depression. One also deals with a lot of adolescent behavior from the inmates, such as the individuals who say that unless they don’t get their way (more food) they are not going to take their medications and thus get sicker. That’s Adolescent Medicine 101.
Some of the modalities I utilized in modifying the jail programs will be familiar to every practicing pediatrician. I educate; I teach; I train. Parents of my asthmatic patients had to know what medications to keep handy and when to use them. It is pretty easy to see how that relates to jail medicine. Many patients come into jail with inhalers and with a diagnosis of asthma. Some have the condition, and some do not. By training jail and medical staff how to observe breathing patterns and by performing pulse oximetry, we eliminated a large number of unnecessary ED visits, and we often made the diagnosis of hyperventilation syndrome rather than misdiagnosed asthma.
Jail medicine is a large part of the cost of housing inmates. I did consultation work for a large urban jail, and we saved over $7 million in 1 year. In a medium-sized jail, the cost-savings after a 4-month consultation was over $300,000. This is a lot of money to me, and I suspect is to you, too. Just as in our general communities, we have enough resources to provide medical care and to provide a high level of care for all. However, we cannot waste money by providing inappropriate care or overtesting or overtreating. The medical care must be what treats the disease the patient actually has ... nothing more and nothing less!
If it sounds as if I am cynical about inmate patients, that is not true. However, I am realistic that no one wishes to be in jail. I realize that the medical route is just one that prisoners can and do use to modify their situation. I understand that the medical staff within a jail needs constant education and supervision at first, and with time they become more astute – just like a physician in this arena – at distinguishing the very serious from the mildly serious from malingering. In spite of this, we doctors also can be fooled. However, through constant vigilance and constant education we can get better.
Jail medicine is not for everyone in retirement. Heck, it is not for everyone ever. I found it interesting because it required me to match my diagnostic skills against the diseases and the psychodynamics of individuals who often – not always – made that diagnosis more difficult. Diagnosing illness and curing it – isn’t this why we all went into medicine?
Dr. Yoffe is a retired pediatrician specializing in allergy and immunology who resides in Brenham, Tex. Email him at pdnews@mdedge.com.
This article was updated 2/13/2020.
Whether “retirement” is withdrawing from one’s occupation or from an active working life, it is of utmost importance to not let one’s mind degenerate. Some individuals move on to gathering new intellectual skills by attending new educational courses or meetings, some travel, some become semiprofessional golfers or fishermen, and some find other forms of personal extension. I now serve to develop cost-saving medical programs for county jails in the state of Texas while attempting to improve the overall quality of inmate care.
Initially I was a pediatrician in Houston with special training in allergy and immunology, but because of a medical problem I was forced to abandon my first love – primary pediatrics. My move to a small town at the age of 40 required me to reevaluate my professional life, and I opted to provide care only in my allergy and immunology specialty.
However, living in a small town is different from life in a metropolis, and it was not uncommon for doctors to be asked to assist the community. A number of years ago, our county judge asked if I would help evaluate why our county jail was spending so much money. After several attempts to refuse, I eventually did evaluate the program there, and was flabbergasted by how much money was being wasted. I made some rather simple suggestions as how to correct the problem, but when no primary care doctor stepped forward to implement the changes and run the jail medical program, I became its medical director. When we saved $120,000 the first year, even I was astounded.
While I continued to run my private practice, I did accept other small community’s offers to look into their county jails’ programs. I found that their problems in cost control and quality of health care mirrored those I found in the first jail, and they were easily solvable if the county judge and the local sheriff wanted solutions. I also found that politics makes strange bedfellows, as the saying goes, and often the obvious changes were met with obstruction in one form or another. Nonetheless, I found that I could serve these communities in addition to my individual patients. When it was time for retirement, I continued to have a real desire to make the towns around which I lived and my own community more livable. So
In most things, I found that the same business philosophy and personal medical approach I learned in my pediatrics training and as a private practitioner applied to the jail system. Let me mention some specifics. Using generic medicines was less expensive than using brand names. The diagnoses which patients claimed when they entered jail might or might not be correct, so reevaluating the diagnosis and treatment was appropriate as soon as possible. Hospital and ED visits should be limited to patients’ medically requiring them rather than using the ED as a screening tool.
But I did come to understand that medical care in the county jail is different from medical care outside an incarcerated facility in that sometimes the prisoners had their own reasons for seeking medical care. This was complicated by the fact that often there were critically ill patients presenting to county jails. So carefully established criteria and protocols were an absolute necessity to save lives.
Let me expand on the topic of seeking medical care by the inmate-patients. A relatively small number of these individuals required immediate emergency treatment, without which they could not do well: The diabetic who was not taking his insulin, the out-of-control paranoid schizophrenic who decided he was cured and therefore was unattended, the alcoholic or drug addict who would develop delirium tremens if medications were stopped abruptly. These people had to be identified as quickly as possible and correctly treated. Confounding the problem was the fact that many, and I repeat many, individuals try to use the medical route to manipulate their incarceration environment. I called this the B problem: beds, blankets, barter, buzz, better food, and be out of here. They might claim an illness existed, and often they might believe it did.
A related situation might exist when individuals would demand psychiatric and pain medications, often in large quantities, when they in fact had not taken them for some time in the outside world. Often these patients were addicts, and of course this could create an entire other relationship with the medical team. A third example would be the claim of hypoglycemia so that the prisoner would receive more frequent meals.
One might think that as a pediatrician I was ill prepared to treat adults, and in fact, there was much review of the general medical care needed when I began this program. However, the internists and family physicians in town were glad to assist me whenever I encountered a difficult patient. When hospitalizations were required, the inpatient always was covered by one of the internists on hospital staff. Quite frankly, the doctors seemed pleased to not be dealing with this group of individuals as much as they had in the past.
On a slightly different note, skills honed during my pediatric career were extremely valuable. Children, particularly young children, do not verbally communicate with their parents or their doctor particularly well, so pediatricians are well trained in the skill of observation. The patient who claims a guard hurt his shoulder so badly during an altercation that he cannot move it is found out when he easily whips his arms over his head when asked to remove his shirt. It is not uncommon for an individual to demand antidepressant medications from the medical staff, but when evaluated more thoroughly and for a longer period of time, the patient ends up laughing, even denying any suicidal ideation or any other sign of depression. One also deals with a lot of adolescent behavior from the inmates, such as the individuals who say that unless they don’t get their way (more food) they are not going to take their medications and thus get sicker. That’s Adolescent Medicine 101.
Some of the modalities I utilized in modifying the jail programs will be familiar to every practicing pediatrician. I educate; I teach; I train. Parents of my asthmatic patients had to know what medications to keep handy and when to use them. It is pretty easy to see how that relates to jail medicine. Many patients come into jail with inhalers and with a diagnosis of asthma. Some have the condition, and some do not. By training jail and medical staff how to observe breathing patterns and by performing pulse oximetry, we eliminated a large number of unnecessary ED visits, and we often made the diagnosis of hyperventilation syndrome rather than misdiagnosed asthma.
Jail medicine is a large part of the cost of housing inmates. I did consultation work for a large urban jail, and we saved over $7 million in 1 year. In a medium-sized jail, the cost-savings after a 4-month consultation was over $300,000. This is a lot of money to me, and I suspect is to you, too. Just as in our general communities, we have enough resources to provide medical care and to provide a high level of care for all. However, we cannot waste money by providing inappropriate care or overtesting or overtreating. The medical care must be what treats the disease the patient actually has ... nothing more and nothing less!
If it sounds as if I am cynical about inmate patients, that is not true. However, I am realistic that no one wishes to be in jail. I realize that the medical route is just one that prisoners can and do use to modify their situation. I understand that the medical staff within a jail needs constant education and supervision at first, and with time they become more astute – just like a physician in this arena – at distinguishing the very serious from the mildly serious from malingering. In spite of this, we doctors also can be fooled. However, through constant vigilance and constant education we can get better.
Jail medicine is not for everyone in retirement. Heck, it is not for everyone ever. I found it interesting because it required me to match my diagnostic skills against the diseases and the psychodynamics of individuals who often – not always – made that diagnosis more difficult. Diagnosing illness and curing it – isn’t this why we all went into medicine?
Dr. Yoffe is a retired pediatrician specializing in allergy and immunology who resides in Brenham, Tex. Email him at pdnews@mdedge.com.
This article was updated 2/13/2020.
Whether “retirement” is withdrawing from one’s occupation or from an active working life, it is of utmost importance to not let one’s mind degenerate. Some individuals move on to gathering new intellectual skills by attending new educational courses or meetings, some travel, some become semiprofessional golfers or fishermen, and some find other forms of personal extension. I now serve to develop cost-saving medical programs for county jails in the state of Texas while attempting to improve the overall quality of inmate care.
Initially I was a pediatrician in Houston with special training in allergy and immunology, but because of a medical problem I was forced to abandon my first love – primary pediatrics. My move to a small town at the age of 40 required me to reevaluate my professional life, and I opted to provide care only in my allergy and immunology specialty.
However, living in a small town is different from life in a metropolis, and it was not uncommon for doctors to be asked to assist the community. A number of years ago, our county judge asked if I would help evaluate why our county jail was spending so much money. After several attempts to refuse, I eventually did evaluate the program there, and was flabbergasted by how much money was being wasted. I made some rather simple suggestions as how to correct the problem, but when no primary care doctor stepped forward to implement the changes and run the jail medical program, I became its medical director. When we saved $120,000 the first year, even I was astounded.
While I continued to run my private practice, I did accept other small community’s offers to look into their county jails’ programs. I found that their problems in cost control and quality of health care mirrored those I found in the first jail, and they were easily solvable if the county judge and the local sheriff wanted solutions. I also found that politics makes strange bedfellows, as the saying goes, and often the obvious changes were met with obstruction in one form or another. Nonetheless, I found that I could serve these communities in addition to my individual patients. When it was time for retirement, I continued to have a real desire to make the towns around which I lived and my own community more livable. So
In most things, I found that the same business philosophy and personal medical approach I learned in my pediatrics training and as a private practitioner applied to the jail system. Let me mention some specifics. Using generic medicines was less expensive than using brand names. The diagnoses which patients claimed when they entered jail might or might not be correct, so reevaluating the diagnosis and treatment was appropriate as soon as possible. Hospital and ED visits should be limited to patients’ medically requiring them rather than using the ED as a screening tool.
But I did come to understand that medical care in the county jail is different from medical care outside an incarcerated facility in that sometimes the prisoners had their own reasons for seeking medical care. This was complicated by the fact that often there were critically ill patients presenting to county jails. So carefully established criteria and protocols were an absolute necessity to save lives.
Let me expand on the topic of seeking medical care by the inmate-patients. A relatively small number of these individuals required immediate emergency treatment, without which they could not do well: The diabetic who was not taking his insulin, the out-of-control paranoid schizophrenic who decided he was cured and therefore was unattended, the alcoholic or drug addict who would develop delirium tremens if medications were stopped abruptly. These people had to be identified as quickly as possible and correctly treated. Confounding the problem was the fact that many, and I repeat many, individuals try to use the medical route to manipulate their incarceration environment. I called this the B problem: beds, blankets, barter, buzz, better food, and be out of here. They might claim an illness existed, and often they might believe it did.
A related situation might exist when individuals would demand psychiatric and pain medications, often in large quantities, when they in fact had not taken them for some time in the outside world. Often these patients were addicts, and of course this could create an entire other relationship with the medical team. A third example would be the claim of hypoglycemia so that the prisoner would receive more frequent meals.
One might think that as a pediatrician I was ill prepared to treat adults, and in fact, there was much review of the general medical care needed when I began this program. However, the internists and family physicians in town were glad to assist me whenever I encountered a difficult patient. When hospitalizations were required, the inpatient always was covered by one of the internists on hospital staff. Quite frankly, the doctors seemed pleased to not be dealing with this group of individuals as much as they had in the past.
On a slightly different note, skills honed during my pediatric career were extremely valuable. Children, particularly young children, do not verbally communicate with their parents or their doctor particularly well, so pediatricians are well trained in the skill of observation. The patient who claims a guard hurt his shoulder so badly during an altercation that he cannot move it is found out when he easily whips his arms over his head when asked to remove his shirt. It is not uncommon for an individual to demand antidepressant medications from the medical staff, but when evaluated more thoroughly and for a longer period of time, the patient ends up laughing, even denying any suicidal ideation or any other sign of depression. One also deals with a lot of adolescent behavior from the inmates, such as the individuals who say that unless they don’t get their way (more food) they are not going to take their medications and thus get sicker. That’s Adolescent Medicine 101.
Some of the modalities I utilized in modifying the jail programs will be familiar to every practicing pediatrician. I educate; I teach; I train. Parents of my asthmatic patients had to know what medications to keep handy and when to use them. It is pretty easy to see how that relates to jail medicine. Many patients come into jail with inhalers and with a diagnosis of asthma. Some have the condition, and some do not. By training jail and medical staff how to observe breathing patterns and by performing pulse oximetry, we eliminated a large number of unnecessary ED visits, and we often made the diagnosis of hyperventilation syndrome rather than misdiagnosed asthma.
Jail medicine is a large part of the cost of housing inmates. I did consultation work for a large urban jail, and we saved over $7 million in 1 year. In a medium-sized jail, the cost-savings after a 4-month consultation was over $300,000. This is a lot of money to me, and I suspect is to you, too. Just as in our general communities, we have enough resources to provide medical care and to provide a high level of care for all. However, we cannot waste money by providing inappropriate care or overtesting or overtreating. The medical care must be what treats the disease the patient actually has ... nothing more and nothing less!
If it sounds as if I am cynical about inmate patients, that is not true. However, I am realistic that no one wishes to be in jail. I realize that the medical route is just one that prisoners can and do use to modify their situation. I understand that the medical staff within a jail needs constant education and supervision at first, and with time they become more astute – just like a physician in this arena – at distinguishing the very serious from the mildly serious from malingering. In spite of this, we doctors also can be fooled. However, through constant vigilance and constant education we can get better.
Jail medicine is not for everyone in retirement. Heck, it is not for everyone ever. I found it interesting because it required me to match my diagnostic skills against the diseases and the psychodynamics of individuals who often – not always – made that diagnosis more difficult. Diagnosing illness and curing it – isn’t this why we all went into medicine?
Dr. Yoffe is a retired pediatrician specializing in allergy and immunology who resides in Brenham, Tex. Email him at pdnews@mdedge.com.
This article was updated 2/13/2020.
Do pediatricians have the courage to demand change?
No child should ever go without adequate medical care in America. The key word here is "adequate," which is not to say that all parents can have whatever health services they wish for their children, whenever they wish, and from whomever they wish. It is this misconception of "adequacy" that undermines our ability to solve or even make a major dent in the cost of pediatric health care in the Medicaid population.
Almost every physician I know or have ever known in a 40-plus year career wants children to receive a high level of health care. Furthermore, most of us realize that it is not the child’s fault that the parents are poor. We don’t care. Most pediatricians and family physicians can and will provide adequate care for the children, according to their health care needs. Where I believe we have failed goes back to our role of physicians as being leaders and teachers who are not afraid to provide these services both to parents and to society, even when society may not wish to hear the truth.
Emergency departments are for emergency care. They are not for individuals who cannot pay their health services bills. They are not for those who find it easier to come to the hospital as an after-hours clinic. They are not for those parents who have failed to distinguish between a true medical emergency and a convenience for themselves and their children.
Parents simply do not know what is and what is not a pediatric medical emergency. The solution to this first problem can be summed up in three words: Education! Education! Education!
Somewhere in the recent past, medical school and residency training programs have misplaced the contract that occurs when a patient and physician agree to a health care relationship. The doctor has a responsibility to provide supervision, instruction, and education, while the patient – or in this case, the parent – has the requirement to follow those leads. When one party does not uphold his or her end of the bargain, he or she must be taken to task. I don’t believe a statement, "The doctor has no more open appointments today, so go to the emergency room at the local hospital," fulfills our end of the contract." We have to do better, and that may mean extended hours, shared call schedules, or other creative approaches to providing care to those infants, children, and adolescents who are sick.
An alternative, but really supplemental, strategy is to teach parents the difference between true emergencies and minor health problems their children will repeatedly encounter so that they are able to choose not to use emergency departments (EDs) for routine care.
What we need is good, solid, easily understandable, and easily usable information for parents so that they are not left with the three alternatives that the State of Texas recently provided in one of its latest parental handouts: call 911; go to the ED; or call your physician. A much better alternative to these three is for parents to become more knowledgeable and more efficient in caring for their own children through an educational program that works. We must not only request that parents become better educated, we must demand that they at least try. If they are not capable, then we must provide the leadership in offering them whatever assistance they need.
As physicians and leaders, we have to provide the right kind of information for parents. Single-page handouts don’t work. They are left in our examination rooms, waiting rooms, and in the parking lot. Furthermore, even the well crafted one-page tools are routinely kept only as long as the current illness is present; then they are misplaced or discarded.
The educational material we do distribute to our new parents must be the right physical size. If you watch the parents in your practice’s check-in area, you often will see a mom with one child in a stroller, a second child in hand, and perhaps a third child repeatedly being requested not to run around the table. Mothers do not bring anything into the clinic or to any doctor’s office that does not fit into "the bag." Most men, and even women without children, have no concept of "the bag." But, if an article, be it a new type of bottle or clothing apparel, does not fit into "the bag," it is not brought to the physician. And parents likely won’t take home any material that won’t fit in there either.
Also, any pediatrician worth his salt understands that if an educational tool, such as a book, is not the correct physical size to sit on the mother’s (or father’s) bedside table, it will not be used very frequently. Parents like ease of use, so they tend to keep medications they are using at night and the instructions for those medications as close as they can, so the size of the book has to fit on the bedside nightstand, too.
Finally, the educational material must, and I repeat must, have brand names and the appropriate dosing in its instructions. Many times, I have asked if the parent has acetaminophen or ibuprofen at home, and I have been given a negative response. Further conversation leads to the understanding that parents do have Tylenol or Motrin in their house, and they know exactly where those medications are. For years, I have recommended that we use brand names in our instructions for another reason – because different companies produced the same chemical antipyretic, but in different concentrations. My heartiest congratulations to the American Academy of Pediatrics in finally getting our legislators to recognize that standardization of pediatric medications is important. Underdosing doesn’t work, and overdosing is dangerous! Not being responsible, educated parents is no longer a reasonable alternative. Again, the three key words are simple ones: Education! Education! Education!
I believe ED physicians have an obligation themselves to enlighten patients about the correct use of the ED facility. In a world in which hospitals are trying to fill their after-hour space – which is the ED – and at the same time achieve patient satisfaction, what young physician is going to risk telling a patient the truth? Who will step forward to plainly state, without malice, that a child’s medical situation is not an emergency, and that they need to first access their primary care physician? That’s right, it is important for the ED physician to state the parent’s needs to establish himself or herself with a pediatrician, family physician, public health program, or clinic so that his or her children can receive the adequate health care for their level of need. That way, the ED is not deluged with runny noses or children receiving their routine immunizations.
On the other hand, the physician treating emergency patients should be treating broken bones, lacerations that are actively bleeding, and fevers that have not returned to normal with reasonable therapy. Those physicians need time to consider the truly ill children so that they can also provide adequately for them. Unfortunately what is more commonly said is, and I paraphrase, "If your child doesn’t get better, you come right back here, and we will see you again." Medicaid must develop and support a screening code so that nonemergencies are not extensively worked-up and aggressively treated in that facility, but instead are referred to an appropriate level of care. At first, this will undoubtedly require retraining of those individuals who have been using the EDs as walk-in clinics, but in the long run, costs will go down and children will receive the level of care they need. I suspect the withholding of payment for overtreatments and overdiagnostic testing may be the only way to achieve these results.
Can we create a better health care system for infants, children, and adolescents when offices are not opened? Sure, we can. However, it will take leadership. It will take physicians standing their ground on what they know is good as well as cost-effective medicine. It will take an educational tool that actually works. Most of all it will take leadership. Fear is never a quality that drives leadership, courage is!
Dr. Yoffe is a retired pediatrician in Brenham, Tex.
No child should ever go without adequate medical care in America. The key word here is "adequate," which is not to say that all parents can have whatever health services they wish for their children, whenever they wish, and from whomever they wish. It is this misconception of "adequacy" that undermines our ability to solve or even make a major dent in the cost of pediatric health care in the Medicaid population.
Almost every physician I know or have ever known in a 40-plus year career wants children to receive a high level of health care. Furthermore, most of us realize that it is not the child’s fault that the parents are poor. We don’t care. Most pediatricians and family physicians can and will provide adequate care for the children, according to their health care needs. Where I believe we have failed goes back to our role of physicians as being leaders and teachers who are not afraid to provide these services both to parents and to society, even when society may not wish to hear the truth.
Emergency departments are for emergency care. They are not for individuals who cannot pay their health services bills. They are not for those who find it easier to come to the hospital as an after-hours clinic. They are not for those parents who have failed to distinguish between a true medical emergency and a convenience for themselves and their children.
Parents simply do not know what is and what is not a pediatric medical emergency. The solution to this first problem can be summed up in three words: Education! Education! Education!
Somewhere in the recent past, medical school and residency training programs have misplaced the contract that occurs when a patient and physician agree to a health care relationship. The doctor has a responsibility to provide supervision, instruction, and education, while the patient – or in this case, the parent – has the requirement to follow those leads. When one party does not uphold his or her end of the bargain, he or she must be taken to task. I don’t believe a statement, "The doctor has no more open appointments today, so go to the emergency room at the local hospital," fulfills our end of the contract." We have to do better, and that may mean extended hours, shared call schedules, or other creative approaches to providing care to those infants, children, and adolescents who are sick.
An alternative, but really supplemental, strategy is to teach parents the difference between true emergencies and minor health problems their children will repeatedly encounter so that they are able to choose not to use emergency departments (EDs) for routine care.
What we need is good, solid, easily understandable, and easily usable information for parents so that they are not left with the three alternatives that the State of Texas recently provided in one of its latest parental handouts: call 911; go to the ED; or call your physician. A much better alternative to these three is for parents to become more knowledgeable and more efficient in caring for their own children through an educational program that works. We must not only request that parents become better educated, we must demand that they at least try. If they are not capable, then we must provide the leadership in offering them whatever assistance they need.
As physicians and leaders, we have to provide the right kind of information for parents. Single-page handouts don’t work. They are left in our examination rooms, waiting rooms, and in the parking lot. Furthermore, even the well crafted one-page tools are routinely kept only as long as the current illness is present; then they are misplaced or discarded.
The educational material we do distribute to our new parents must be the right physical size. If you watch the parents in your practice’s check-in area, you often will see a mom with one child in a stroller, a second child in hand, and perhaps a third child repeatedly being requested not to run around the table. Mothers do not bring anything into the clinic or to any doctor’s office that does not fit into "the bag." Most men, and even women without children, have no concept of "the bag." But, if an article, be it a new type of bottle or clothing apparel, does not fit into "the bag," it is not brought to the physician. And parents likely won’t take home any material that won’t fit in there either.
Also, any pediatrician worth his salt understands that if an educational tool, such as a book, is not the correct physical size to sit on the mother’s (or father’s) bedside table, it will not be used very frequently. Parents like ease of use, so they tend to keep medications they are using at night and the instructions for those medications as close as they can, so the size of the book has to fit on the bedside nightstand, too.
Finally, the educational material must, and I repeat must, have brand names and the appropriate dosing in its instructions. Many times, I have asked if the parent has acetaminophen or ibuprofen at home, and I have been given a negative response. Further conversation leads to the understanding that parents do have Tylenol or Motrin in their house, and they know exactly where those medications are. For years, I have recommended that we use brand names in our instructions for another reason – because different companies produced the same chemical antipyretic, but in different concentrations. My heartiest congratulations to the American Academy of Pediatrics in finally getting our legislators to recognize that standardization of pediatric medications is important. Underdosing doesn’t work, and overdosing is dangerous! Not being responsible, educated parents is no longer a reasonable alternative. Again, the three key words are simple ones: Education! Education! Education!
I believe ED physicians have an obligation themselves to enlighten patients about the correct use of the ED facility. In a world in which hospitals are trying to fill their after-hour space – which is the ED – and at the same time achieve patient satisfaction, what young physician is going to risk telling a patient the truth? Who will step forward to plainly state, without malice, that a child’s medical situation is not an emergency, and that they need to first access their primary care physician? That’s right, it is important for the ED physician to state the parent’s needs to establish himself or herself with a pediatrician, family physician, public health program, or clinic so that his or her children can receive the adequate health care for their level of need. That way, the ED is not deluged with runny noses or children receiving their routine immunizations.
On the other hand, the physician treating emergency patients should be treating broken bones, lacerations that are actively bleeding, and fevers that have not returned to normal with reasonable therapy. Those physicians need time to consider the truly ill children so that they can also provide adequately for them. Unfortunately what is more commonly said is, and I paraphrase, "If your child doesn’t get better, you come right back here, and we will see you again." Medicaid must develop and support a screening code so that nonemergencies are not extensively worked-up and aggressively treated in that facility, but instead are referred to an appropriate level of care. At first, this will undoubtedly require retraining of those individuals who have been using the EDs as walk-in clinics, but in the long run, costs will go down and children will receive the level of care they need. I suspect the withholding of payment for overtreatments and overdiagnostic testing may be the only way to achieve these results.
Can we create a better health care system for infants, children, and adolescents when offices are not opened? Sure, we can. However, it will take leadership. It will take physicians standing their ground on what they know is good as well as cost-effective medicine. It will take an educational tool that actually works. Most of all it will take leadership. Fear is never a quality that drives leadership, courage is!
Dr. Yoffe is a retired pediatrician in Brenham, Tex.
No child should ever go without adequate medical care in America. The key word here is "adequate," which is not to say that all parents can have whatever health services they wish for their children, whenever they wish, and from whomever they wish. It is this misconception of "adequacy" that undermines our ability to solve or even make a major dent in the cost of pediatric health care in the Medicaid population.
Almost every physician I know or have ever known in a 40-plus year career wants children to receive a high level of health care. Furthermore, most of us realize that it is not the child’s fault that the parents are poor. We don’t care. Most pediatricians and family physicians can and will provide adequate care for the children, according to their health care needs. Where I believe we have failed goes back to our role of physicians as being leaders and teachers who are not afraid to provide these services both to parents and to society, even when society may not wish to hear the truth.
Emergency departments are for emergency care. They are not for individuals who cannot pay their health services bills. They are not for those who find it easier to come to the hospital as an after-hours clinic. They are not for those parents who have failed to distinguish between a true medical emergency and a convenience for themselves and their children.
Parents simply do not know what is and what is not a pediatric medical emergency. The solution to this first problem can be summed up in three words: Education! Education! Education!
Somewhere in the recent past, medical school and residency training programs have misplaced the contract that occurs when a patient and physician agree to a health care relationship. The doctor has a responsibility to provide supervision, instruction, and education, while the patient – or in this case, the parent – has the requirement to follow those leads. When one party does not uphold his or her end of the bargain, he or she must be taken to task. I don’t believe a statement, "The doctor has no more open appointments today, so go to the emergency room at the local hospital," fulfills our end of the contract." We have to do better, and that may mean extended hours, shared call schedules, or other creative approaches to providing care to those infants, children, and adolescents who are sick.
An alternative, but really supplemental, strategy is to teach parents the difference between true emergencies and minor health problems their children will repeatedly encounter so that they are able to choose not to use emergency departments (EDs) for routine care.
What we need is good, solid, easily understandable, and easily usable information for parents so that they are not left with the three alternatives that the State of Texas recently provided in one of its latest parental handouts: call 911; go to the ED; or call your physician. A much better alternative to these three is for parents to become more knowledgeable and more efficient in caring for their own children through an educational program that works. We must not only request that parents become better educated, we must demand that they at least try. If they are not capable, then we must provide the leadership in offering them whatever assistance they need.
As physicians and leaders, we have to provide the right kind of information for parents. Single-page handouts don’t work. They are left in our examination rooms, waiting rooms, and in the parking lot. Furthermore, even the well crafted one-page tools are routinely kept only as long as the current illness is present; then they are misplaced or discarded.
The educational material we do distribute to our new parents must be the right physical size. If you watch the parents in your practice’s check-in area, you often will see a mom with one child in a stroller, a second child in hand, and perhaps a third child repeatedly being requested not to run around the table. Mothers do not bring anything into the clinic or to any doctor’s office that does not fit into "the bag." Most men, and even women without children, have no concept of "the bag." But, if an article, be it a new type of bottle or clothing apparel, does not fit into "the bag," it is not brought to the physician. And parents likely won’t take home any material that won’t fit in there either.
Also, any pediatrician worth his salt understands that if an educational tool, such as a book, is not the correct physical size to sit on the mother’s (or father’s) bedside table, it will not be used very frequently. Parents like ease of use, so they tend to keep medications they are using at night and the instructions for those medications as close as they can, so the size of the book has to fit on the bedside nightstand, too.
Finally, the educational material must, and I repeat must, have brand names and the appropriate dosing in its instructions. Many times, I have asked if the parent has acetaminophen or ibuprofen at home, and I have been given a negative response. Further conversation leads to the understanding that parents do have Tylenol or Motrin in their house, and they know exactly where those medications are. For years, I have recommended that we use brand names in our instructions for another reason – because different companies produced the same chemical antipyretic, but in different concentrations. My heartiest congratulations to the American Academy of Pediatrics in finally getting our legislators to recognize that standardization of pediatric medications is important. Underdosing doesn’t work, and overdosing is dangerous! Not being responsible, educated parents is no longer a reasonable alternative. Again, the three key words are simple ones: Education! Education! Education!
I believe ED physicians have an obligation themselves to enlighten patients about the correct use of the ED facility. In a world in which hospitals are trying to fill their after-hour space – which is the ED – and at the same time achieve patient satisfaction, what young physician is going to risk telling a patient the truth? Who will step forward to plainly state, without malice, that a child’s medical situation is not an emergency, and that they need to first access their primary care physician? That’s right, it is important for the ED physician to state the parent’s needs to establish himself or herself with a pediatrician, family physician, public health program, or clinic so that his or her children can receive the adequate health care for their level of need. That way, the ED is not deluged with runny noses or children receiving their routine immunizations.
On the other hand, the physician treating emergency patients should be treating broken bones, lacerations that are actively bleeding, and fevers that have not returned to normal with reasonable therapy. Those physicians need time to consider the truly ill children so that they can also provide adequately for them. Unfortunately what is more commonly said is, and I paraphrase, "If your child doesn’t get better, you come right back here, and we will see you again." Medicaid must develop and support a screening code so that nonemergencies are not extensively worked-up and aggressively treated in that facility, but instead are referred to an appropriate level of care. At first, this will undoubtedly require retraining of those individuals who have been using the EDs as walk-in clinics, but in the long run, costs will go down and children will receive the level of care they need. I suspect the withholding of payment for overtreatments and overdiagnostic testing may be the only way to achieve these results.
Can we create a better health care system for infants, children, and adolescents when offices are not opened? Sure, we can. However, it will take leadership. It will take physicians standing their ground on what they know is good as well as cost-effective medicine. It will take an educational tool that actually works. Most of all it will take leadership. Fear is never a quality that drives leadership, courage is!
Dr. Yoffe is a retired pediatrician in Brenham, Tex.
