Simple Advice That Will Simplify Your Life Part III - Make Your Doctor Your Friend
Dear Readers,
I recall writing in the past about the importance of collaborating with your children’s doctor by being straightforward and reporting their entire medical history, even if you are uncomfortable with revealing some sensitive information (It was titled “Partner With Your Physician” and should be uploaded to my website doctorsimai.com soon).
Today, I would like to discuss another important aspect of a doctor visit, namely your child’s examination.
In medical school, there was heavy stress on the importance of obtaining a proper History of present Illness. I recall that in my 3rd year of medical school, I was taught that 90% of the time, a doctor should be able to make a diagnosis by obtaining the history alone, without examining the patient. The examination in many cases, came just to confirm the suspicion. Recently, I read in a journal that if a physician is unsure of the diagnosis after spending 5 minutes obtaining history, he is in trouble!!!!
I reflected on this idea before writing this article, and wondered if this idea is true in the field of pediatrics? After all, its hard to tell if someone is wheezing, has an ear infection or strep throat based on the parent report alone. Very often, a child can present with “the perfect recipe” for an ear infection fever, congestion and pulling on the ears, but on examination show pearly, clear ears. On the other hand, a parent may describe an infant with a “mild cold” that turns out to be an infant with severe respiratory distress on examination. So in many cases, pediatricians can not afford to skip the exam and make assumptions.
Alas, in the past few years, I have noticed a disturbing dangerous phenomena that may put our patients in danger. What I am referring to is not the fact that doctors are rushing through visits without properly examining their patients. I am referring to is the fact that we, physicians have to literally fight through to get access to examine some of our patients. If you feel that I am making this up, here is an example of recent scenario I encountered.
A young mother recently came in with her 2 year old daughter and reported that she has been coughing badly the previous night. After spending a few minutes obtaining the history, I suspected that the child suffered from “croup”. She had a barky cough, worsening at night, a low grade temperature and mild runny nose. She was sleeping in a warm room with her windows closed. As I gathered this information, I was trying hard not to jump into conclusions before examining the cute girl, but I did discuss steps that the mom could take to relieve dry, barky coughs. When I proceeded to examine the girl, she started looking more fearful. She just turned 2, so I did not expect to have a fully cooperative patient, but I offered to give her a sticker and waited for a few moments before resting my stethoscope on her chest. After auscultating the lungs front and back, I asked the mom to help me check her ears and there came the shocking reply: “doctor whats the point of this? It’s pretty obvious that my daughter has the croup, so why do we have to torture her and check her ears and throat?” I was truly shaken to hear this.
Although I was partially desensitized to this “obstruction to care”, because it is regrettably commonplace already for some parents to try and physically shield their child and hold them in position that makes it nearly impossible to examine, this was the first time a parent actually demanded that I should NOT examine the child’s ears and throat. So in order to illustrate the importance of such thorough examination, I decided to share the following story with her:
It was on a Motzei Shabbos (Saturday Night) a few years ago that my friend from medical school called me at home. David my wife and I are on away vacation and my my 3 year old son is running a fever and has been literally barking back at home. My mother is babysitting and is extremely nervous, but being that my regular doctor is away, do you mind stopping by my house and quickly checking him just to calm my mother down? Luckily, I had no special plans that night and was happy to help a good friend. I walked into the house, and after hearing the history from the Bubbie and hearing the boy cough, I surmised that the 3 year old indeed had the croup. However, I started checking the child as I always do. His lungs were crystal clear (yes, croup affects the upper airways, not the lungs), his ears were pearly and his throat looked perfect. Then, I asked him to lift his head and look at the ceiling, and there, in his left nostril, laid a large white object. The boy was a little embarrassed when we asked him if he shoved something up his nose, but with Gd’s help, a few minutes later, I was able to remove a white piece of lego from the cute boy’s nose. I told the Bubbie what to do with the barky cough and called my friend to give him a quick report.
Now, I turned to the mother at my office and asked: if I was going to follow your assumptions that a barky child does not need an examination of the ears, nose and throat, what would happen to the little boy? How would his parents feel about my pompous assumptions? Yes, I made the diagnosis of croup, but did I fulfill my role as a physician? I reminded the mother that she invested so much time, effort and money coming into my office. Why would she prevent me from giving her daughter the care that she deserves?
During routine well visits, I perform a scoliosis check on every teenager. Every year or two, I find a young patient with severe scoliosis on their exam. When that time comes, after discussing the diagnosis and the steps that ensue it, I mention to the parents that their child made it worthwhile for me to examine the backs of about one thousand teenagers. Some of the most memorable moments in my life is getting a tearful thank you from mother of a nine and a half year old child that had her scoliosis diagnosed on my exam and received the treatment before it advanced to disfigure her back. How could I face the same mother and say that I skipped her daughter’s scoliosis exam because she was “uncomfortable” or difficult to examine? (it is performed in a Tnius way) Or just because I assumed that based on her family history, she was at a low risk of having scoliosis? I do not think that I became a doctor so I could start making assumptions and cut visits short to save time and effort.
In the Five Towns, we are blessed with great access to healthcare. We live in a community that produces top notch physicians, and have a truly great line up of Pediatricians. We are the envy of other communities, where people have to travel miles and sit in crowded waiting rooms for hours, if they are lucky enough to see their doctor and not waste time in Emergency Rooms. I feel that as responsible parents, we should work together with the doctors to facilitate the proper examination of our children.
Yes, most children under 3 fear their doctors and they have all the right in the world to do so (they are usually sent home with a good bye that includes several shots in their arms). However, I strongly feel that if a parent shows the proper reaction and stays calm when a doctor approaches to examine their child, the child will feel more comfortable when he is being examined. When a child observes that the parent pulls him away from the doctor, or sees the parent cringe when the doctor simply looks in the child’s nose or ear, the child gets the wrong message. He detects that the doctor is inflicting pain, rather than infusing health. Another easy way to stir this fear is by telling your child “if you don't eat your supper I will take you to the doctor and ask him to give you a shot”. On the other hand, if you tell your child: “if you are nice to your sister, I will take you to the doctor and tell him that you were so helpful he will surely reward you with a sticker and a lollipop”, you will remind your child that the doctor is his friend and your child will actually look forward the encounter with his doctor.
Naturally, I noticed that most toddlers become my best friends between 23 years old. I attribute it to the fact that they grow more mature and confident, and have mostly finished associating doctors with pain as their immunizations are usually completed by their second birthday.
However, children whose parents suffer from anxiety could be heard screaming when I walk into the room even at the age of 4 and 5 years old. In a few cases I noticed that these 4 and 5 year old screamers, never received any vaccinations at all!!! So what was behind these shouts? I genuinely feel that sometimes, the parent’s negative feelings and fears of their doctor trickled down to their kids.
On the flip side, I see many parents that stay calm and relaxed while I clean their kid’s ears and offer a smile when the child opens their mouth wide for a strep test. Their children emerge from my office stronger and with a good feeling of accomplishment. The children conquer their fears and understand that life includes some minor but necessary pains. They truly earn their lollipops and stickers!!!!
So lets try to raise a healthier and calmer generation of children. Let us instill confidence in our kids, rather than fear of being checked. Let’s “play doctor” with our kids and have them look forward to see their physician. Let’s tell our kids that their doctor is their true friend.
This advice may one day, just save the little people for whom you pray.
With Love,
David E. Simai M.D.