Do pediatricians have the courage to demand change?
Also, any pediatrician worth his salt understands that if an educational tool, such as a book, is not the correct physical size to sit on the mother’s (or father’s) bedside table, it will not be used very frequently. Parents like ease of use, so they tend to keep medications they are using at night and the instructions for those medications as close as they can, so the size of the book has to fit on the bedside nightstand, too.
Finally, the educational material must, and I repeat must, have brand names and the appropriate dosing in its instructions. Many times, I have asked if the parent has acetaminophen or ibuprofen at home, and I have been given a negative response. Further conversation leads to the understanding that parents do have Tylenol or Motrin in their house, and they know exactly where those medications are. For years, I have recommended that we use brand names in our instructions for another reason – because different companies produced the same chemical antipyretic, but in different concentrations. My heartiest congratulations to the American Academy of Pediatrics in finally getting our legislators to recognize that standardization of pediatric medications is important. Underdosing doesn’t work, and overdosing is dangerous! Not being responsible, educated parents is no longer a reasonable alternative. Again, the three key words are simple ones: Education! Education! Education!
I believe ED physicians have an obligation themselves to enlighten patients about the correct use of the ED facility. In a world in which hospitals are trying to fill their after-hour space – which is the ED – and at the same time achieve patient satisfaction, what young physician is going to risk telling a patient the truth? Who will step forward to plainly state, without malice, that a child’s medical situation is not an emergency, and that they need to first access their primary care physician? That’s right, it is important for the ED physician to state the parent’s needs to establish himself or herself with a pediatrician, family physician, public health program, or clinic so that his or her children can receive the adequate health care for their level of need. That way, the ED is not deluged with runny noses or children receiving their routine immunizations.
On the other hand, the physician treating emergency patients should be treating broken bones, lacerations that are actively bleeding, and fevers that have not returned to normal with reasonable therapy. Those physicians need time to consider the truly ill children so that they can also provide adequately for them. Unfortunately what is more commonly said is, and I paraphrase, "If your child doesn’t get better, you come right back here, and we will see you again." Medicaid must develop and support a screening code so that nonemergencies are not extensively worked-up and aggressively treated in that facility, but instead are referred to an appropriate level of care. At first, this will undoubtedly require retraining of those individuals who have been using the EDs as walk-in clinics, but in the long run, costs will go down and children will receive the level of care they need. I suspect the withholding of payment for overtreatments and overdiagnostic testing may be the only way to achieve these results.
Can we create a better health care system for infants, children, and adolescents when offices are not opened? Sure, we can. However, it will take leadership. It will take physicians standing their ground on what they know is good as well as cost-effective medicine. It will take an educational tool that actually works. Most of all it will take leadership. Fear is never a quality that drives leadership, courage is!
Dr. Yoffe is a retired pediatrician in Brenham, Tex.
