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Friday, August 24, 2007

Post#2 The Power of Follow-up

Of the many doctors that will one day infiltrate your life and perhaps your body, you as an individual/mother/father/caretaker will no doubt ask yourself, "Do I trust this doctor?" It is a fair and necessary question. But it is likely that of all the M.D.s who come in and out of your life, the one who you will scrutinize the hardest is your pediatrician (and perhaps your OB/Gyn). And for good reason - they are your partners in caring for what is likely the most important thing in your life, your child. And you pray and hope they don't screw up. Talk about pressure.

By "trusting" your pediatrician, you likely hope for a cost-effective yet effective, innocuous yet proven, thorough yet uncomplicated treatment each time your child becomes ill.

When presented with a sick child, there is a careful and structured thought process that I go through to come up with the best treatment plan. But before concocting a solution, I must first ascertain what the correct diagnosis is. I would estimate that 60% of the diagnoses I make each day are bread and butter pediatrics, simple enough such that an astute pediatric resident at the end of their 1st year of training could come up with the correct answer without assistance.

Another 30% of my patients may not present as cut and dry, but I can easily group them into an unofficial diagnostic category such as "viral illness with a funky rash which should resolve without any complication".

It is the final 10% where my experience, fund of knowledge and creativity come into play. And truth be told, the majority of this 10% will go on to good health, regardless of any intervention or medication. It is in this last 10% where follow-up visits are my most powerful and cost-effective ally.

Imagine you are a contestant on an updated version of the 5o's game show Name that Tune. If you are an iPod junkie, you may be able to correctly name 80% of songs with just a few bars of music. Certain songs are so distinct, that it wouldn't take even an average music fan but a few notes to decipher what they are listening to. Ala You Give Love a Bad Name, Hit Me with Your Best Shot, Play That Funky Music, White Boy, etc.

But other songs may take a few more lines. For example, the notorious Ice Ice Baby could easily be mixed up with Queen's classic song Under Pressure (not that Vanilla plagiarized. C'mon - he was keeping it real!). You get my point. Some diagnoses only take a few notes, others may require a follow-up visit or two.

At the end of a visit in which the diagnosis is not clear, a pediatrician can:

A. Order a battery of tests to shed some light on the matter.

B. Try medication(s)/treatment(s) and hope something works.

C. Consult a specialist.

D. Send the child to the ER.

E. Have the child return for a follow-up visit.

Each of these choices is appropriate in certain situations. However, each has a potential downside. Tests are often expensive and possibly harmful (radiation) or painful (blood draws). Medications can also be expensive and can lead to possible side effects. Specialists are often expensive as well and may feel compelled that the buck has to stop here, leading to unnecessary treatments/tests. The ER is insanely expensive, and you may have a less qualified doctor than your pediatrician helming the ship. Finally, a follow-up visit may be the most cost-effective measure; however, the child may become sicker or there may be no additional clues which present themselves at the follow-up visit.

The pediatrician must carefully choose which of these options is the most appropriate in each situation. If I think I have a bead on a possible diagnosis, I will sometimes order a test to see if I am correct. If I have a strong hunch on a possible diagnosis, I may even empirically treat. If I am perplexed, I may elicit the help of a specialist. If I am worried that a child is decompensating, I may send them to the ER. However, the most likely scenario is that I just need to see the history of the disease play itself out. And thus, it is the almighty follow-up visit which aids me the greatest in murky situations.

Once a child is deemed stable, a follow-up visit is usually the cheapest, most pain-free, side-effect free and hassle-free plan of action that can be taken for the family. Given that most kids are resilient, many will improve by the time they follow-up with me. Or in the event that they remain ill, a few more symptoms will surface to help make the proper diagnosis and treatment plan. Simply by waiting a few hours or days, I can avoid the egregious error of crediting Vanilla Ice with a true Queen classic. And all this whilst I am under pressure.

5 comments:

paul said...

good entry

Wendy said...

my 9 month old was treated for an ear infection 8 days ago. she seems much better but is still fussy and swatting her ear. is it normal to have to pay for a follow-up visit just for her doc to look in her ear?

Thanks,

Wendy in Austin, TX

Peter Jung said...
This comment has been removed by the author.
Peter Jung said...

Wendy,
The answer is yes. There is actually a contractual obligation for the doctor to do so. The main reason is doctors and patients alike could abuse insurance coverage by waiving all copays not just on follow-up visits, but on any visit really, which would then make it more attractive for the patient to utilize the doctor and the insurance more frequently. The copay acts as an internal check system to prevent egregious overuse /abuse of the insurance. On another note, it used to be and currently is common practice for doctors to have all children return for follow-up visits on ear infections. For children under 1 year of age, I think this is a good idea simply because they are not verbal and the ear space is anatomically less forgiving; however in older children I usually instruct the mother to follow-up only if the child does not seem to be improving/getting worse. Often, children will have fluid lingering in their ears for several weeks after an ear infection and medically speaking there is not a whole lot that can be done for this. Well controlled studies have demonstrated that prophylactic antibiotics, antihistamines, steroids, etc. do little for the fluid in the ear. Unfortunately, time is the best healer. Because colds precede ear infections, and one ear infection often begets another, and because your child will likely have several colds this winter, be prepared for more infections in the very near future. Ultimately the follow-up visit for a child under one year of age is to make sure that your child is heading in the right direction, and that they will not require a second or third line antibiotic (which is needed in the event that the ear infection is secondary to an antibiotic resistant organism).

Wendy said...

Thanks so much for your reply. I ended up taking her in and she did still have 2 infected ears so the Dr. gave her a different antibiotic.