Thursday, July 22, 2010

The Sad Part of Pediatrics

I'm never sure where the line in the sand is between appropriate blogging and toeing HIPAA, but what I was taught in med school was follow the letter of HIPAA and this situation has been eating at me and needs to get blogged.

One of the things that I love about being a pediatrician and having my own clinic is the continuity of care. I am these people's pediatricians. I had my fourth visit with a four-week old today and it was the most awesome thing ever. Next week, I have a visit with one of my babies from the nursery, the younger brother of one of my patients and a well visit with one of my personal patients. That's also totally awesome. (The best thing about the newborn nursery is when I ask patients who they want their pediatrician to be and they say "can I come see you?")

Things that are less totally awesome: having continuity of care means I'm the one who knows when the ball gets dropped. So one of my babies is still in the "neonatal" period (first month of life) and has missed twice as many visits than it is weeks old. They've come to a whopping one visit. While at that one visit, I felt like the parent was really disengaged and they even left the room while I was examining the baby. They didn't schedule another visit, so I called the family and reminded them how important it was to be seen. They agreed, I gave them the benefit of the doubt and overbooked my schedule in order to see them at a convenient time for the family.

I think this story is going somewhere obvious, but I was still really sad when they didn't show up. So, luckily, I have good social work resources. So we did some exploring. And there are...other issues (the kid isn't really getting fed) and we've warned the family that this is likely going to become a DHS case (our version of CPS). But it makes me really sad. I feel guilty for my role in getting authorities involved, even though I know that it is absolutely the best for this kid. I want to believe that every parent is trying to make things work and is doing their best for their kid. But in a lot of ways, that's a naivete born out of primarily doing inpatient peds, where parents cared enough to at least bring their kid to medical attention when things were bad. I really hope things turn out OK for this kid, but also for this family and that having authorities involved will be a needed wake up call.

Sunday, July 18, 2010

Prenatal/Neonatal Visits

One of the problems that I think faces all doctors is that we lose perspective on the gap between what we know and what most people know. This is particularly obvious in my newborn visits. Like most doctors when doing newborn teaching for a family my goals are
1. Making sure that the family is feeding the kid correctly
2. Making sure that the kiddo is being put to sleep in a safe environment
3. Making sure that they're using a carseat and doing so correctly

Many doctors also use this time to talk about smoke detectors and smoking and carbon monoxide detectors, but I'm a rebel. I will see my newborns again in one week, and it's pretty unlikely anything will change on that front, so I can talk about those things at the two week visit. Why do I care? Because there is only so much information that parents can handle. And instead of talking about smoke detectors, etc. I try to answer the most common parents concerns (both that they have at the newborn visit and that will cause them to come back unnecessarily between the newborn and the two week visit)
1. The equivalence of the hospital brand of formula and the formula that WIC gives out (This is the number one question I get asked)
2. Things normal newborns do -- sleep a lot, get blue hands and feet, breathe funny and strain when they poop (I also try to talk about the line between the normal form of each of these and their pathologic equivalent and when it's worth bringing the kid in for a sick visit.) In infants with dark skinned parents, I like to let them know the skin will get darker (in my patient population fathers worry about mistaken paternity because the newborn is light).
3. Things many normal newborns have -- I let parents know if their kid has a murmur or an umbilical hernia or a hemangioma and that it's normal and how I expect it to change over time.
4. Things that I expect to change before they see me again -- kiddo should start eating more, jaundice should fade, if stools haven't changed from meconium they will, formula kids may get constipated (and that's OK)
5. Things that have already happened and what they meant -- most parents do not understand why their kid got a hepatitis B vaccine in the nursery, what the newborn screen was for, what "that test that they took the baby away to do" was (hearing), or why the baby had black stools at birth and I usually go over some of that.

So by the time we're done going over all of that it's a HUGE amount of information. And that's before I have the nurse come in and give them teaching on how to use a rectal thermometer and how to mix formula. It's a ton of information.

In Ohio, we had new parents come in for prenatal visits. I could talk to them about everything except the particular normal variants that their kid had. Then we would review at the newborn visit, and I would have the time to talk about smoking and home safety and all that jazz and they would have room in their brain to listen. For some unknown reason we don't offer prenatal visits here and I feel like everyone loses out from that.

The time to tell parents how to properly feed a newborn is not when the newborn has already been at home for five days. I'd love to reinforce the need for a jaundice check at day of life three or four, but when parents don't come in to see me until the kid's a week old, at that point there's nothing I can do.

I also think that there's some (a minority) of pediatricians who make up for the lack of prenatal visit and still manage to cram in home safety by sacrificing discussing parental concerns. And I think the reason that happens is that pediatricians lose sight of the knowledge gap. The result is that I've had kids come into the emergency room for glabellar hemangiomas (a normal birthmark. Also called an "angel kiss.") When this happened I asked the parents "Hasn't the kid had that since birth" and they said "well, yes, but it kept getting darker and darker and now he's crying and it's even darker." So I asked, "what did your pediatrician tell you about it?" And they said "oh, our pediatrician never mentioned it."
So it's possible that the pediatrician did give them a great talk on what the hemangioma was and what to expect and the parents didn't remember (because they were on information overload!)
But there are also pediatricians for whom hemangiomas are so routine (about 25-50% of babies have one) that they forget to teach about them. And then, as hemangiomas do, they get darker with time and darker when the kids cry and the parents panic.