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.