Welcome to another edition of Portable Practical Pediatrics! I’m your host Dr. Paul Smolen, also known as Doc Smo. From gestation all the way to graduation, if it involves children, we discuss it here. Today we are going to take on the question of what trait or traits make a great physician? How do you know if you have a just an average pediatrician or you’ve got one that is a cut above? Are the best doctors the ones that got the highest scores on exams in med school or the ones who have seen the most patients? Or are the best doctors the ones that are the friendliest, best looking, and have the best bedside manner? Since I have been practicing and teaching pediatrics now going on 36 years, the question of good doctoring traits is one that I have pondered for some time. Certainly, excellence involves a lot of factors but here is what I have concluded after a my long career in medicine; the doctors who are the best observers, take sufficient time and attention to get a thorough understanding of the child’s symptoms, and then judiciously do testing to either confirm or deny their conclusions–those are the best physicians. In short, the best physicians are the ones that are the best listeners. The famous physician of the 19th century, William Osler who help found the Johns Hopkins Medical Center, said it best when he remarked, “Listen to your patient, he is telling you the diagnosis.” In medicine, this is called getting a good history. Today we are going to explore the art of diagnosis from a doctor’s perspective. I am going to pull the curtain back on the diagnostic process behind your child’s visit to the pediatrician and explore things you can do to maximize the value of your child’s next visit to their health care provider.
Most parents are really good observers.
I have found that most parents are excellent observers of their children and their physical symptoms. Most can give an accurate, detailed, and useful description of their children’s signs and symptoms. I must say however, that this is often more true of Mom’s than it is of Dad’s. Generally speaking, mothers can give a more accurate description than can fathers because they often, spend more time with their children. That only makes sense to me. Now here is something to consider before your child’s next pediatric visit; Doc Smo Pearl: “Anything that gets in the way of your pediatrician’s careful history taking process weakens your child’s visit.” This reality is particularly important when a child is brought to the doctor for a more complex problem such as chronic stomachaches, a prolonged fever, or an unusual rash. Asking the right questions, getting an accurate description of the child’s symptoms, and carefully listening to their answers is what good medicine is all about and what the best doctors do well. Being a good doctor is synonymous with being a good engaged listener and observer.
Things that get in the way of a good history:
But parents need to understand that there are many things that can get in the way of their pediatrician being able to obtain a really good and accurate history. Let’s go through a few of them:
-Multiple children at a visit-You can imagine the scene– 4 kids of various ages in am 8X10 exam room, fighting over a few books or toys. This often means chaos and not only is the doctor distracted from the issue at hand, but so is the parent history giver.
-A very anxious or exhausted parent-These emotional states often distort and hinder a parent’s accurate recall of their child’s symptoms. Additionally, now, instead of focusing on the child and their symptoms, the pediatrician is now dealing with Mom or Dad’s anxiety rather than the symptom at hand. In these situations, much of my energy is going toward defusing the parent’s emotional state rather than learning more about the child’s symptom.
-Similarly, a parent who is mad at whoever or whatever is often not able to describe their child’s symptoms accurately-This often happens when a divorced parents or parent of a child in daycare who is sick all the time brings their child for a visit. The parent’s level of stress is so high that their ability to relate good observations about their child just isn’t there.
-And finally, some parents just can’t stay focused on the questions that the pediatrician is asking long enough to impart useful information. They go off in other directions and really don’t answer the question at hand. I don’t know if their inability to answer stems from nervousness or an inability to focus on the topic but some parents just can’t do it. This situation is very frustrating for everyone.
Things that enhance a pediatric visit:
OK, now that you have some sense of what can interfere with your pediatrician getting accurate information, let’s explore what factors can be helpful and enhance a pediatric visit:
Cell phones with photos, sound and video recordings, and digital diaries have revolutionized the life of a pediatrician. Now I can see and hear the symptoms that parents are worried about, even if they are not happening during the visit. Need to see what that rash looked like last night? No problem, here it is doc! Was that sound your baby was making a stridor or a wheeze, well; here is what it sounded like doctor with video to boot. Decide for yourself Doc Smo! Or do those stomaches follow the consumption of certain foods, here is my spreadsheet; decide for yourself. Cell phones are cameras, video recorders, high-end audio recorders, and diaries all wrapped up in one little device. Amazingly useful. https://www.docsmo.com/diagnosis-via-cell-phone-pedcast/
OK, here is another tip to enhance your pediatric visits. Send your “A team” observers to give your child’s doctor the history, especially if the problem seems complex. And make notes before you go so you won’t forget your thoughts while you are there. I remember one particularly observant parent, actually a Dad in this case, who noticed that one of his twins was getting sick way more often that the other twin, with fever and an inflamed throat. This Dad also noticed that there was a uniform cycle to his son’s sicknesses, happening about every 4-6 weeks. After four or five cycles of this pattern, he convinced me that something strange was going on. And he was right. After all the dust settled, it turned out that his child had something called “Periodic fever”. This child’s Dad was able to make the needed observations that got his son the correct specialists and obtain the correct diagnosis and treatment. Way to go Dad.
Pediatricians who know your child and have a long term relationship with them are going to be the best at helping them gain insight into their physical symptoms. A 16 year old who trusts his pediatrician enough to admit that there is verbal and physical violence at home during their visit for headaches has just taken a short cut to both diagnosis and treatment of his headaches.
We have seen that the most important factor involved in helping a sick child is time. Having enough time for your child’s health care provider to listen, ask, and watch. Specialists usually have 1-hour slots for patients instead of the 15 or 20 minutes pediatricians are given for visits. Since pediatric visits are shorter than many others, if you are bringing your child to the doctor for a chronic problem or a very worrisome symptom, try and make those visits without other kids coming along, at a time when you won’t be rushed, and a time when your child’s doctor is likely not too stressed; early morning visits and early afternoon visits. That way, you can both take the time to explore your child’s symptom from every angle. I think good medical care is 80% history, 15% physical exam, and 5% testing.
Summary-What do the Best doctors do?
So let’s summarize the traits that mark the best doctors:
–Best doctors get a thorough history. Taking enough time to explore a child’s symptoms is vital to helping your child. And remember, your child is probably not able to chronicle their symptoms or simply don’t remember their details. They depend on you to do that.
–Best doctors test their diagnosis with lab tests whenever possible and backup and rethink your child’s problem if the tests don’t confirm what they thought. Doing cultures makes judicious use medicines rational and precise. Cultures such as throat cultures and urine cultures are one of the most powerful tools a pediatrician has at their disposal. Blood tests and genetic testing allow your child’s pediatrician to detect things that they just can’t see.
–Astute pediatricians don’t hesitate to recruit help from specialists when it is needed. Your child may present their pediatrician with a rare and unusual illness and your child’s pediatrician may never have seen this condition before. Their willingness to ask colleagues for help is not a sign of a weak doctor but one who knows what he or she doesn’t know. I believe that really strong pediatricians don’t have a problem saying “I don’t know” but when they utter those words, in the next breath they also say, “But I will find out”.
–As I mentioned earlier, best doctors use all the tools at their disposal like photographs, video, recordings, symptom diaries, the Internet, their partners, and even books!
–And finally, and most importantly, the very best doctors know how to really listen and observe.
Well thanks for joining me today. If you enjoy exploring the world of pediatrics with pedcasts, take a moment to like and share interesting episodes with friends, recommend Portable Practical Pediatrics to other parents, and even write a review on iTunes or Facebook. We would love to hear what you have to say. This is Doc Smo, recording in studio 1E, hoping you will take stock, of what makes a best doc. Until next time.
Appropriate use of strep cultures