Tag Archives: Pediatrics

From the desk of Doc Smo- The “New” Face of Pediatrics

I must say I have had a wonderful career in medicine and pediatrics.  Not only is pediatric medicine intellectually challenging, but it also has tremendous personal rewards.  A day in the life of the pediatrician is filled with sore throats, injured ankles, ear infections, anxious parents, as well as new babies and teens getting ready to go off to college.  My days are full of noise, icky smells, and crying children but also moments of great triumph and pride.  Triumph when your doctoring skills are truly able to make an improvement in a child or family’s life, and pride when you know you got it right: you brought the combination of knowledge, insight, and communication skills together to diagnose your patient’s problem and resolve it.


With all this in mind, I read with great interest an article in the Academy of Pediatrics newspaper that boasted about how many young doctors are now choosing pediatrics as a career.  Pediatrics is a hot specialty again.  Imagine that.  This year, young doctors filled 98.7% of pediatric residency positions (training programs after medical school graduation) despite the fact that, year after year, pediatrics is the lowest paid specialty in medicine.  Additionally, more men are becoming pediatricians!  What is going on here?  Do these “guys” know something that I don’t, or does Generation Y have more wisdom than I realized? Could it be that the procedure based medical system I have known my entire career is changing to a more preventative, contemplative one in the near future?  Move over orthopedic surgeons, meet the next generation of physicians who are skilled with the use of  prevention and cognitive services    Time will tell how this will work out and I will be watching with interest. Until next time.

What Makes an Effective Doctor Visit? (Pedcast)

Have you ever stopped to think what makes an effective visit to the doctor?  Get Dr. Smolen’s perspective on the subject from the doctor side of the equation in today’s pedcast.  Dr. Smolen outlines what he considers essential features of a well run visit to the pediatrician.



DocSmo here welcoming you to another edition of DocSmo.com, the podcast that helps parents with issues from the diapers to the diploma, from the crib to the country club, from the bassinette to the board room… well, you get the idea.



I have been training young doctors for 30 years

One of the things I certainly want them to learn is how to perform and provide an effective evaluation of a sick child.

During my long career I have given a lot of thought as to what makes a good sick visit both for the doctor and the patient.

So today I thought it might be fun for my listeners to hear what this pediatrician considers the essential elements that make a doctor visit effective.

I have previously done a podcast on how to choose a doctor as I see it.  Today you are going to get a little more on that subject as I reveal what I think makes a good visit to the doctor.

After listening to today’s cast, you will have an idea if your child’s doctor would meet the quality standards that I have strived to achieve for myself and my physician students.

In today’s pod cast I will concentrate on the sick visit and not the well supervisory visits.

Let’s go ahead and jump right in, shall we?


So here we go, you are in the exam room and the doctor walks in.


I think the visit should start with an introduction to both the parent and the child.  I like to shake hands or bump elbows during flu season…you know, the CDC approved handshake.

Next comes the ceremonial and visible washing of hands.  Let’s start clean, that’s important.

An open-ended question usually starts the visit which brings up something I consider really important…parents and children need a chance to tell their story without interruption. The families have prepared what they are going to say and it is important that as doctors, we give them a chance to say it in an unhurried manner.

After they have given us what they consider important information, then we as doctors are free to start asking all the questions we want.

I like to let the child who is old enough to have a chance to answer as many of the questions as possible. It’s good practice for them and I get to see their reaction to their symptoms, often very valuable information. After all the history is collected, I try and repeat the important stuff back both to let them know I was listening and make sure I have the story right.


Next comes the examination, which may be difficult for many children.  I always try and do this on the child’s level and in a position that is most comfortable for the child.

For toddlers, that’s being held.

For older children, I try and tell them as much of what I am doing as possible as I do it.  They seem to appreciate this.

Once I have gotten the history and done my exam, it’s time to talk out loud

At this point it’s time to teach.

I explain what I think is happening, why it is happening, and whether there is anything I think will help.  Often this leads to a discussion of the natural history of a particular illness and maybe a little science talk… long time listeners know DocSmo loves science talk.

I give the family some measures that may be helpful and I make sure that there is a plan that is clearly described.  I try and repeat the plan twice or I sometimes even write it down.  I probably should do more of that than I do.


I think it is important to give the family an idea of what new symptoms would worry me and prompt a call back, thus opening the door to feel free to call back with worries


This is the beauty of private practice, of knowing your patients well. I am almost guaranteed follow up for those who need it.  They know and trust me and my staff,  and most of the time are very comfortable calling and giving us follow up.  Rarely do we have a patient who gets much worse after a sick visit without our knowledge.


So, that’s my take on how to provide an effective sick visit: It’s really pretty simple:

The process should include a comfortable and effective exchange of information between the family and the doctor that ensures accuracy and completeness. In my business, gathering a history and listening carefully is the most important part of most visits.

Next, we try and achieve an examination of the child that is as unobtrusive and comfortable as possible for the child.

Next, I think it is important for the doctor to create a conclusion and plan that is clearly laid out and repeated to ensure understanding and agreement.

And finally before leaving, a parent should understand that  they can call back with questions or concerns as well as  know what to look for should the child’s condition deteriorate.



That’s one pediatrician’s take on a good sick visit and I am anxious to hear your perspective.

Feel free to write in with your observations and comments, I welcome them

If you think as doctors we do something poorly, tell us!

I think this cast may generate a lot of interesting comments, or at least I hope so.

If you like what you hear in these DocSmo pod casts, share them with your friends.  I won’t stop you if you want to write a 5 star comment on itunes and be sure to subscribe so you will get the latest content hot off the DocSmo press.  If you are a face book fan, like us there or follow us on twitter.

This is Dr. Paul Smolen, broadcasting from studio 1E, that’s my first child’s bedroom on the east side of the house, hoping that you now have a lock on your next visit to the doc.

Until next time.

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From the desk of Doc Smo: A Constipation Conversation (Article)

How many ways can constipated children come to the doctor?
I am totally amazed at the myriad of presentations that constipated children present to their doctors. I remember listening to MANY complex lectures in medical school and residency about recurrent abdominal pain and trying desperately to memorize the LONG list of conditions that present as recurrent abdominal pain in children. After all these years of clinical practice, common sense has finally taken precedence. Hold onto your seats for this DocSmo pearl: “Common things are uncommonly common.” In other words, don’t look for exotic illness when, most likely, everyday maladies are probably at work. Humans have two “common” reasons their stomachs hurt:

1. A lower intestine that is not completely emptying (Constipation)
2. An overly acidic stomach that doesn’t empty well and may actually reflux (send contents backwards) into the esophagus.

Let’s take a moment to talk about the first cause, constipation. Little kids—and even big ones—sometimes find pooping unpleasant. At some level they avoid it, and it catches up with them. When it does, they come to the doctor complaining of cramping pain (hollow organ trying to empty), feeling sick after eating (nowhere for food to go from the stomach), gas (excess fermentation in the colon), burping (slow gastric emptying), back pain (referred pain), vomiting (no room in the Inn), bloating, leaking stool, rectal pain, prolapse of the rectum… and the list continues. I am sure that another 30 years will bring many new variations on the same theme.

I really think we may have been better off when we lived outdoors, pooping wherever and whenever. I doubt children growing up in those conditions ever had stomachaches for the reasons we do now. Everything has to be so perfect for our children. They need to poop at the right time (when an adult says it’s ok), only in “approved” places, and quickly and cleanly: the so called Demand Poop. No wonder all the fuss!


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The Lunchroom Lowdown: Bathroom Boot Camp (Article)

I was telling my partners about Bathroom Boot Camp at lunch last week. The topic of potty training comes up regularly for pediatricians, and they were happy to share their experience for this blog. I posed the question, “What have you found are important things for families to remember when training and maintaining continence in their children?” Their answers were very informative. Here is a glimpse:

Dr. Monica Miller, one of my young “GenX” partners, felt that reward and a positive attitude are important. Parents need to set the correct ambiance and mood. She feels that the bathroom experience should be slow, not rushed. She also emphasizes highlighting success. She recommends a “Potty Parade” after each success: “Let’s celebrate! The toilet success is so important that we need to have a party!” Her approach emphasizes patience, praise, and fun. Dr. Miller thinks that the most difficult children to train are those who are very intelligent or those who have difficulty adjusting to uncomfortable sensory experiences.


Dr. John Plonk, on the other hand, is one of the older doctors (mid fifties) that I work with. He is definitely a boomer. He grew up on a farm with days full of hard farm labor. His young life was dominated by work, dirt, and animals, so his attitude is “let’s get the job done.” He suggests letting children observe animals around them, learning through imitation. “Everyone pees and poops,” he says, “even animals. Children just need to observe what is happening around them and do as they do.” Being outside most of the day facilitates training since the deeds can be done anywhere; this method encourages children to take charge and be the masters of their own domains. Also, it’s hard to mess up too badly outside. Dr. Plonk recommends celebrating success with what he calls Flushing Fiestas: “Kids love to flush toilets, so make that their reward for cooperation when indoors.” Dr. Plonk also feels that a diet rich in “P” fruits promotes success: pears, plums, peaches, pomegranates, and popcorn. A great suggestion, and easy to remember. He recommends avoiding bananas and limiting dairy and cheese during the training process, for obvious reasons.


Dr. Kimberly Riley“If your stomach hurts, you need to poop, it’s that simple.” No wimpy poop for her patients, they need good volume. To achieve this, she emphasizes the relaxed bathroom, much like Dr. Miller. She recommends taking advantage of the gastro-colic reflex, the reflex that empties your child’s colon just after eating. “Routine toilet sitting is important, and don’t rush.” She encourages the parents of her patients to allow videogame use only in the bathroom. Dr. Riley declares, “Finally a good use for a video game!” Amen. Dr. Riley also points out that the school setting is particularly bad for regularity for many children since they do not have free access or adequate time in the bathroom while at school. Be aware of this fact as a parent, and make the necessary adjustments when possible. Dr. Riley feels that the strong willed child is the most difficult to train.

I hope some of these insights are helpful to families as they deal with the often-difficult task of potty training. I think the main thing to remember is that all normal children eventually master the entire bathroom experience. Be patient and don’t go negative. Remember, your child is the only one who can actually control their sphincters, both rectal and urinary; to have ultimate success, your child needs to take control. I recommend creating an environment that cherishes success and encourages independence. Good luck.


For a complete list of this week’s potty content, check out the topic of the week!


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