Tag Archives: pediatrics

Vs Retail Clinics-Are We Going to Whine or Win?

26 Feb

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http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/44450

I noticed the headlines rolling in Monday about the AAP updated policy statement regarding retail based clinics.  The one above particularly caught my eye.  Something about the tacking on of “Again” caught my attention.  It came across to me like we (pediatricians) were perceived to be saying something that was unnecessary, maybe even that we were just complaining. 

Throughout the day, I monitored my Twitter feed and read some articles discussing the issue.  Fortunately, I didn’t see a whole lot to confirm my (perhaps defensive) concern that we would be perceived as whining about the emergence of urgent and retail clinics.

But, the guideline and the response from the retail clinics got me thinking.  Currently we seem to be doing OK in the public perception but how much longer does that hold up?  Are our statements going to forever be met with an understanding or is there eventually going to be backlash about our perceived inflexibility.

There are many things that parents want in medical care for their children but I believe this debate boils down to 2 main issues:

Quality

Convenience

Quality

Pediatricians claim, in the policy, that retail based clinics create a decrease in quality of care for the following reasons:

  • Fragmentation of care
  • Provision of episodic care to children with special health care needs and chronic disease
  • Lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information
  • The use of tests for the purposes of diagnosis without proper follow-up
  • Possible public health issues that could occur when patients with contagious diseases are in a commercial, retail environment with little or no isolation (eg, fevers, rashes, mumps, measles, strep throat, etc)

I do believe these are concerns that do need to be addressed by the urgent care and retail people.  I have written about many of these previously: My Questions for Urgent Care Clinics

The AAP policy statement goes on to make recommendations for principles with retail clinics (my thoughts italicized):

  • Supporting the medical home model: RBCs should support the medical home model by referring the patient back to the pediatrician or other primary care physician for all future care.  (Is this realistic?  They might even say that they will but will we eventually tell our patients that they should have just used the retail clinic for this complaint because it was simple?  This won’t happen and I don’t know why we’d expect them to refer back to us either.)
  • Communication: The AAP recommends that RBCs promptly communicate with the patient’s pediatrician or other primary care physician within 24 hours of the visit.   (This seems logical and important.)
  • Using evidence-based medicine: The AAP recommends that all those providing care to children follow all AAP clinical guidelines as well as those guidelines developed by other medical organizations that have the support and endorsement of the AAP.  (Again, a reasonable and critical expectation.)
  • Contagious diseases: By providing medical care to individuals in a retail-based setting, RBCs must take the necessary precautions to prevent the spread of contagious diseases.  (While many pediatricians do this, it is not universal and we need to do a better job of providing well and sick waiting rooms.)

Many of these concerns are addressed in the quote from the article:

The Convenient Care Association, a Philadelphia-based retail clinic association, took exception to the AAP’s claims about its members’ work.

“Retail clinics work closely with local physicians and pediatricians. They all use electronic health records (EHR) and actively encourage the sharing of visit records with a patient’s family physicians and pediatricians in order to facilitate continuity of care,” Tine Hansen-Turton, JD, the association’s executive director, said in a statement. “Additionally, the industry is very focused on quality care, and EHRs are also used in clinics to monitor evidence-based practice performance.”

Whether or not you agree with the assessment, they do provide an answer to many of the concerns that the AAP has raised.

Convenience

The second major issue I see arising as a result of the conversation is about convenience.

Let’s imagine that the retail clinics drafted a policy statement that addressed their concerns regarding care at pediatrician’s offices.  Some of their concerns might go something like this:

  • Lack of same day illness appointments creates unnecessary overnight suffering for parents and children.
  • Small waiting rooms create difficult environments for parents managing active kids.
  • Minor complaints should be seen by mid-level providers and escalated as necessary to the physician.
  • Parents’ schedules are malleable and need the flexibility of walk-in appointments.
  • Parents need the ability to have their children seen outside of their typical working hours to avoid lost income.

These are some of the benefits of convenience that a retail clinic provides that many of us currently do not or we meet it in some trivial way that does not provide a real solution for families. 

Don’t get me wrong, we have come a long way.  Improving the patient/parent experience has always been a focus of pediatrics and will continue to be for years to come.  But, there is some reason that our patients are using these clinics (and why we have to issue statements about them) and I would guess that for the most part it’s a convenience issue. 

So, we’re still missing the boat (and an opportunity) somewhere.

The Race Is On

The way I see it, the race is on.  One of two things are going to happen.

  1. Retail clinics are going to figure out solution to our perception of their decreased quality of care and the public will know about it.  The quote from Tine Hansen-Turton, JD tells me that they are already far along in their thinking and ready to make strides to improve their quality of care.  They can’t afford to stop trying because it means their future success or failure.
  2. Pediatric offices are going to figure out a way to meet the demand for patient convenience that is currently being met by the retail based and urgent care clinics.  We need to make ourselves agile enough to meet the demands of convenience as they arise in the future.  We can’t afford to stop trying because it means our future success or failure.

Which is it going to be?  Are we going to whine or win?

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Nosebleeds-Help in a Flash

26 Feb

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Nosebleeds are very scary for parents but there are few nosebleeds that have concerning causes.

The most common causes of nose-bleeds are: dry air and nose-picking (or both).

Many children will have allergies which dry out the tissue inside.  This causes cracking with minor trauma or picking.  It is well supplied with blood vessels, it will bleed like crazy.

Make it Stop!

  1. Hold the soft part of the nose just below the bridge for FIVE minutes.  If  you stop to check, it can start again because the cracks open.
  2. Do not have the tilt their head back unless you think they would like the taste and feel of swallowed blood in their stomach.  It doesn’t help.
  3. If still bleeding after 5 minutes, it can be helpful to put something cold over the nose to help constrict the blood vessels.
  4. If you cannot control the bleeding, go to your doctor or the ER.

Preventing Frequent Nose Bleeds

  1. Run a humidifier
  2. Spray nasal saline spray or put vaseline in the nose
  3. Clip the child’s nails short and smooth

Concerning Signs

If any of these are present, you need a doctor visit:

  • Fever
  • Weight loss
  • Easy bruising
  • Small red dots all over

Ankle Injuries-Help in a Flash

24 Feb

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Photo credit Jacob Moore (elementmotif.com and oilfieldimaging.com)

 

Another weekend down, another injury free weekend at 4 yo t-ball so that I haven’t felt compelled to out myself as a pediatrician to my son’s team.

Ankle sprains are one of the most common sports injuries in older children/teens.  All sports (except running) have some side-to-side movement that any “graceful” athlete can tip over and hurt themselves.  Even if your child avoids tripping over themselves, they can step on bases and other children’s feet.

What do you do with a sprained ankle?

  • Rest-No need to completely restrict movement.  Should be allowed to do what they can (walk, run then sport when pain improving).
  • Ice-Apply 20 minutes twice a day.
  • Motrin-To help with pain and inflammation.

Who needs a doctor’s visit?

  • Pain is severe
  • Pain in lower leg bones or bumps at the side of the ankle
  • Unable to put any weight on the foot

Who needs a brace?

Only those that have had repeat ankle sprains.  Bracing after the first sprain is unnecessary and potentially harmful. 

I would only recommend bracing in conjunction with your doctor.  Too many kids are wearing braces around indefinitely with no plan.

Warts-Help in a Flash

21 Feb

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Warts are one of the most annoying problems.

They are not caused by holding (or kissing) frogs but, instead, are caused by viruses.

The virus that causes warts is contagious but that does not necessarily mean that if your child touches a wart they will get one.

Warts will go away on their own without treatment (Say it with me now.)   It never feels like that when it’s your own child, but I promise they will.  It may take 6 months to 2 years but they will go away.

There are many strategies for taking care of warts at home. 

OTC Meds

  1. Bath or shower
  2. Use an emery board to file the dead skin on the surface
  3. Apply the topical wart remover
  4. Cover the wart with a band-aid

Duct Tape

Place a strip (or ring if on the finger/toe) over the wart.  This strategy may take weeks or months of coverage to work but it does work (studies even show it)

Wart removal can be done but I only recommend it for warts that are painful or in a location that makes activities (writing, etc) difficult. 

The most common types of removal are freezing and laser therapy.

Frequent Urination-Help in a Flash

20 Feb

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Has anyone ever said this before?

First you’re annoyed, then you start to get a little more concerned.  Could something be wrong?

This is usually normal and will go away but there a few things to think about:

Urinary tract infection

It will usually be accompanied by pain with urination, fever or belly pain.

Diabetes

The child will also typically have increased thirst or hunger and weight loss.  It is pretty unusual to diagnose diabetes from frequent urination in young children but I have had a 2 year old in my practice that was so not impossible.

Both of the above require a urine sample so going to the doctor is a must.

Abnormal Voiding

The most common cause.  Two reasons, the child is not emptying their bladder when they do go (usually nervous about missing something) or they have gotten in the habit of going as soon as they feel the slightest stretch on the bladder. 

You can help with these problems by having your child go “just a little bit more” after they go and by asking them to wait a minute or two after they say they need to go in order to go.

Night Terrors-Help in a Flash

12 Feb

Sound asleep (or up watching the Olympics-who can sleep with curling on?), you wake up to the earth-shaking, ear-piercing sounds of your child screaming down the hall!

The first night it scares you to death, and then it happens over and over again.  Who am I kidding? It scares you to death every time.

What is the difference from a  nightmare?

Night terrors-

  • Occur during non-REM sleep (no dreaming)
  • Child is unable to be consoled (no matter what)
  • Child goes back to sleep without awakening
  • No memory of what happened

Why is there no memory?

  • Children are in a deep sleep the whole time
  • There are no images to remember

What causes nigtht terrors?

  • New environments
  • New medications
  • Child is over-tired
  • You (or the other parent-family history)

What can you do?

  1. Wait it out (I know this is hard for all of you and particularly hard for some)
  2. Make sure they are safe (not falling off the bed, etc)
  3. Do no wake them up (are more confused/scared and harder to get back to sleep)

And finally, work on finding a way to get yourself back to sleep after that adrenaline rush.  (You can start by praying that it doesn’t happen again tonight.)

Sleep Jerking-Help in a Flash

11 Feb

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It could go like this:

“Honey, come look at this!  What is he doing?”

You walk over to the monitor and see your child doing a couple of quick jerks.

Or this:

Your child is sick with a fever so you pull them up into bed with you.

Next thing you know, you get a rapid punch to the face or kick in the knee by a child that is completely asleep.

Those rapid “shock-like” jerks are called myoclonus.  They can occur anytime but often occur during sleep.  They are usually single jerks but 2 or 3 are not concerning.

They tend to increase in activity when a child is sick, especially with fever.  This makes them concerning to parents for many reasons: 

  • Is this happening because they are sick?
  • Does this mean that they are really sick?
  • You are paying closer attention to them, even during sleep.
  • Parents bed share when children are sick.

I have great news!  There’s nothing to worry about!

These movements are normal.  Everyone does them to some degree.

You should notify your doctor if:

  1. Jerks happen in series of more than 3
  2. Jerks happen during the day while the child is awake
  3. You have associated concerns (especially neurologic or developmental)
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