Momwithastethoscope's Weblog

October 1, 2009

Loving Pediatric Medicine – the anti-rant recap

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:03 am
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Here’s a rundown of reasons to love pediatrics:
Reason Number 1: Pediatrics is about prevention.
Reason Number 2: Tickling toddler toes.
Reason Number 3: Making a connection with patient & parent

Reason Number 4: Shopping my brain for tailored advice for patients.
Reason Number 5: New Stuff
Reason Number 6: Being anti-pain
Reason Number 7: Medicine in the age of the internet.
Reason Number 8:  Cultural diversity in my practice.
Reason Number 9: Research and information gathering.
Reason Number 10:  Toys.
Reason Number 11: Loyal adolescent male patients.
Reason Number 12:  Twins.
Reason Number 13:  My partners.
Reason Number 14:  Books for patients and parents
Reason Number 15: Books 2: Books for doctors by doctors
Reason Number 16:  A-Ha! Moments
Reason Number 17:  Kid’s Hair
Reason Number 18:  Pediatrics is a specialty
Reason Number 19:  Making a specialty within pediatrics
Reason Number 20:  Concierge medicine @ home
Reason Number 21:  Foreign bodies

Reason Number 22: Tricks of the trade

Reason Number 23:  My community

Reason Number 24:  New Parents

Reason Number 25:  Follow-up Phone Calls

Reason Number 26:  Intuition

Reason Number 27:  Patience

Reason Number 28:  Rashes

Reason Number 29:  Life out of the office

Reason Number 30:  Spouse support

September 26, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: pediatrics,positive medicine,Synchronicities — momwithastethoscope @ 4:14 pm
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Reason Number 26:  Intuition. 

It is always with excitement that I wake up in the morning wondering what my intuition will toss up to me, like gifts from the sea. I work with it and rely on it. It’s my partner.” Dr. Jonas Salk 

 For some patient encounters, evidence-based, rooted –in- science medicine doesn’t answer all the questions.  It is during these times that I rely on my silent consultant, intuition.  My logical mind would like to resist these encounters, but an intuitive “hit” is like IV caffeine to the rest of my brain.  And like Dr. Salk said, “Intuition will tell the thinking mind where to look next.”

A-ha moments are born of intuitive hits.   Early in my career, I diagnosed a sweet, eight year old with leukemia.  She was pale and appeared ill, but she could have looked that way for a number of reasons.  Even the oncologist I referred this patient to noted that she could be sick from a wicked viral infection.   A bone marrow biopsy confirmed the diagnosis that I had suspected before her blood count came back.  This patient’s mother came to me one day after her daughter was treated and in remission and asked me how I knew that her daughter had leukemia.  I didn’t have a good answer – leukemia is one of those illnesses a general pediatrician will see lots of in residency but very few in private practice. (Fortunately!)

Most hunches about my patients and their families are not this extreme.  I use this radar to strike a balance between what parent’s desire from a medical encounter and what’s called for depending on the complaint.   Disharmony in families will lead to visits to my office.  While surveys such as those used by Mary Caserta, MD and Peter Wyman PhD in their research connecting childhood illness to family stress are used in controlled settings, I have found that my own intuition is a good barometer.  Sometimes I’m the tie-breaker is a difference of opinion between spouses or other family members.  Sometimes those “oh-by-the-way” hand on the door moments are parents reaching out for a sounding board. 

Maybe intuition is just accumulating experience, but I doubt it.  Hunches and gut feelings remind me that I’m not in this medicine business by myself – that some other force is at work as I navigate my way through the lives of my patients.

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:49 am
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Reason Number 27:  Patience

My residency director described me as zealous.  I was a bit taken back when he announced this at our graduation dinner.  To me the term meant militant maybe even with terrorist tendencies – Yikes!  Not exactly the touchy-feely pediatrician you would take your babies and children to, huh? On introspection with the help of Miriam – Webster, I’ve come to realize the postive aspects of being zealous – ardent, eager, passionate.  That impetuous side works well in emergencies and in critical care settings, and knows how to prioritize information and tasks.

Yet most of pediatrics is not emergencies, and I have had to learn the fine art of patience.   Parenthood has taught me to slow down and wait, but medicine, pediatrics, and patients – despite the breakneck speed of practice – has drilled lessons of composure into me, too. 

Patience is waiting for a toilet-training two year old to return from the bathroom.  It is letting a parent tell his or her reason for the appointment in more than 20 seconds before interrupting.  Patience is knowing that Roseola takes a big fever before declaring itself with a rash.  Patience is waiting for a phone call from a subspecialist.  It is coaching a reluctant patient through an ear examine, throat swab, or suture removal.  Being patient is embracing flexibility and letting the day flow.  Patience is gentleness. presence and listening. I hope that’s how my patients remember me.

September 25, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: pediatrics,positive medicine — momwithastethoscope @ 7:47 am
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Reason Number 25:  Call Backs. 

Yesterday, I was sitting on a bench at my son’s school waiting for him to finish his extracurricular activities when one of the front desk staff approached me.

“Do you remember calling me about my son?  He’s 18 now, but in the third grade he had a kidney stone, and you called while we were on vacation to check on him.”

I wracked my brain – ten years and close to 40,000 patient visits later, I was having a difficult time recalling the call.

“I’ll never forget that you called us then.”

Certain patients niggle my brain.  I’ll think about them when I’m in the car or shopping in the grocery store.  Sometimes I worry about them.  Sometimes I’m just curious to see how a visit to a subspecialist went.  When I can, I like to pick up the phone to check on them.  I wish I called back more, but it’s just not possible in the controlled chaos that is my pediatric office.  

Calling back takes effort – finding a phone number, making the space for a couple of quiet minutes   when I won’t be interrupted.  It’s worth the effort, the instantaneous feedback.  Sometimes e-mail suffices – although phone calls feel more personal.  In a perfect world, I’d call all my patients back – check to see if that antibiotic helped the ear infection, hear how the jaundiced newborn was eating, follow-up on the discharge from the hospital for H1N1 –  the response would enhance my medical care.

September 24, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Parenthood,pediatrics,positive medicine — momwithastethoscope @ 5:46 pm
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Reason Number 24:  New parents.  My primary hospital is a 120 bed community facility with an active labor and delivery unit.  Approximately 80 families add a new member there each month.  Despite the pushes and pulls of running a growing (outpatient) pediatric practice, I have maintained my hospital privileges to see the newborns and their families.  For most , a new baby is a very happy time, and I thrive on that optimism. 

Especially for first time parents, advice abounds.  From grandparents. From friends. From the medical staff. Even from the stranger ahead in the check-out line in Target.  With more access to information, parents are more well-read than ever.  Despite the amount of information or maybe because of the volumes of it, new parents have lots of questions.  The perinatal period opens a window in the minds of new parents, and they are often hungry for valid opinions.  My role is to coach – go through the pros and cons of a decision – help them test the waters of their new roles – with common sense and objectivity.

My own children have nurtured the coach in me.  They’ve taught me flexibility, and to see that they are people with opinions, too.  They’ve also taught me that realism and common sense.  Prior to my firstborn, I quoted all the statistics about the values of breastfeeding to my new parents.  The evidence was so clearly stacked that I bought a wiz bang breast pump anticipating my new role as working, breastfeeding mother.  That pump never left the box.  Firstborn Will came out with clear intentions that the claustrophobic work of nursing was not for him – he cried and cried every time I tried to latch him. I cried and cried, too, feeling my first taste of “failure” as a pediatrician/mom.  A weak milk supply didn’t help matters, either. 

That experience was the foundation of the spiel I give to new parents.  Each parent has an inner voice or gut feeling that tells them the right way to nurture their child – pay attention to that voice as it is rarely wrong. Watching and guiding parents to find their groove is a very rewarding part of my job.

Loving Pediatric Medicine – the anti-rant

Filed under: pediatrics,positive medicine — momwithastethoscope @ 5:43 pm
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Reason Number 23:  Community.  In my first pediatric practice, my senior partner told me “Take care of your community, and they will take care of you.”  Heeding his advice, I took my dry cleaning to the family business who brought their six children to our practice, and I frequented other local businesses with young families and children.  Now in my own practice in another community, I still value that wisdom from almost 15 years ago.  This informal network has built a group of patients that I enjoy seeing in my office, but also around town.

September 22, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Uncategorized — momwithastethoscope @ 3:02 pm
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Reason Number 22: Tricks of the trade. Let me define what I mean by tricks – skills gained by experience – not pranks or deceit. A great deal of rapport with children lies in the trust they instill in me as their doctor. So pulling a fast one on a three year old can do a lot to dismantle the sometimes fragile bridge between us. Being deliberate and truthful with all ages of patients goes a long way for me.
One of my favorite aspects of pediatrics is the first hospital visit after a baby is born. Often, relatives and friends gather in the room of the new parents. After introducing myself, I like to scoop up the newborn under the arms supporting the baby’s buttocks with my other hand and gently bounce the infant. Many times, the baby will open his or her eyes and regard the well-wishers. For some parents, this is the first opportunity to gaze into the eyes of their child. This same technique calms crying babies, too, so it is helpful on return visit when new parents feel sleep deprived and frazzled. The bounce helps me determine if a baby wants to be held – those babies quiet quickly when moved up and down – versus a hungry infant who needs to be fed. Bouncing babies also helps waken a sleepy baby as most are in the first 24 hours after delivery.
Mary Poppins sang about a spoonful of sugar helping the medicine go down. I’ve found that to be true. Prednisolone syrup tastes pretty bad – no matter how sophisticated the flavoring. All have a slick, oily aftertaste that makes me gag and many children vomit. Liquid amoxicillin-clavulenate and cefpodoxime are also poor in the taste category. Chocolate syrup is my go-to spoonful of sugar, but I have the occasional patient who doesn’t like sweet tastes or chocolate. For these I usually suggest chasing the medication with a teaspoon of barbeque sauce. To be a good “chaser” for medication – the flavor needs to be dense with a thick texture. I’ve suggested honey-mustard sauce and ketchup. Ranch dressing also gets a nod of approval.
Do you have a trick of the trade to make your job in medicine easier? E-mail me @ momwithastethoscope@gmail.com and I’ll devote a future post to your ideas.

September 20, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Parenthood,pediatrics,positive medicine — momwithastethoscope @ 7:10 am
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Reason Number 20:  Concierge Medicine @ home

On more than one occasion, I have treated my own children.  The lines get a little blurry between when I doctor my children as a mom and when I work on them as a physician.  The afternoon that my then five year old discovered yellow jackets chase you  and stung him 13 times was a mom-treated incident.  Intuitively, I dunked my frightened son in a big tub of lukewarm water and baking soda while I whacked the straggling yellow jackets. 

On another occasion, I had my MD hat on firmly as I watched my youngest struggle with RSV (respiratory syncytial virus).  With his wheezing growing more and more audible from the rotten virus, Harry got more and more still as he worked harder to breathe.  I suspected this fourth night into his illness that we were in for a rough night,  and I borrowed the pulse oximeter from the office to watch his oxygen levels.  He hovered in the low 90% range for most of the night while his chest retracted around his ribcage.  I pulled out my mom care, too, with lots of humidity and pushing him to drink enough electrolyte solution so that he wouldn’t get dehydrated.  The next two nights were equally tough as I watched his oxygen level bounce close to the point where I thought we needed to go to the hospital for oxygen and further treatment. I kept my partners up to date on his progress since we knew he was on the bubble for admission.  Tired and second guessing myself , I noticed a pretty good improvement on the seventh night, and knew we were pulling through. 

Harry’s older brother, Will,  got a taste of mom in MD mode as a vacation at the beach was ending.  In a game of beat-the-clock, my husband and I were trying to get us packed up and checked out when we discovered that young Will had shoved one of my broken earrings up his nose.  Why he chose that moment we’ll never know, but I immediately went into action to avoid an ED visit and still check-out on time.  Will knew I meant business as I came after him with eyebrow tweezers and a headlock.  In retrospect, his cooperation was the key to the success of the earring-ectomy. We pulled away from our beach rental with minutes to spare as I gripped the pearl – a souvenir from the trip that I hadn’t anticipated.

The knack of concierge medicine at home is having second opinions close by.  My husband is an integral part of that equation as are my partners.  Even if I think I know the answer, I lean on this support system to validate my thoughts.  Occasionally I feel silly when I ask for back-up but it’s a small price to pay to do the right thing for my most important patients.

September 19, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:32 am
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Reason Number 19:  Specialty in a specialty

At one point in my career, I wondered if I had taken a wrong turn by choosing general pediatrics.  As a resident, my neonatology attending encouraged me to subspecialize – preferably in neonatology.  While I really enjoyed the NICU – the rotation allowed me to do procedures, attend deliveries, care for really sick patients, and care for unusual problems – the ethical dilemas I encountered took their toll on my young interests.  This attending told me I would be bored in general pediatrics taking care of runny nose after runny nose. 

I have never been bored in general pediatrics. Quite the opposite.  Just when I think that my practice is humdrum, a patient will arrive with a zebra – a problem seen mostly in textbooks and on board exams.  My medical curiosity will smack me between the eyes as I dig in annals and journals and zebra websites.  So that time I was pondering the value of general pediatrics was not from the mundane.  Instead and because of the amount of information I am expected to keep in my cranium, I pondered fine tuning my specialty choice. 

I applied for fellowship in a very competitive specialty, dermatology, and as no surprise to anyone but me, I was not chosen for the extra training despite a shortage of pediatric dermatologists in the area.  No regrets about the experience.  I am meant to be in general pediatrics. 

Now with partners and the prowess of mentors, I see myself able to specialize in an informal way.  Already, my nurses will say to my younger partners, “Ask Dr. MWAS about that – she likes rashes.” Fellow pediatricans in my town have marketed themselves as “specialists” in ADD or autism.  I’m not ready to market myself, but I do see that I can develop a niche in my own practice.  It’s nice to be able to refer to my own partners because of special interests they have in areas of pediatrics.

So I may never hang the shingle for pediatric derm at my office, but my scheduling staff steers dermatological concerns my way.  And I’ll keep working on that knowledge base so that maybe one day I can trade a day of general pediatrics for pediatric dermatology.

September 18, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:51 am
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Reason Number 18:  The specialty of pediatrics

In a typical week, I refer patients to lots of different specialists – ophthalmology, cardiology, pediatric surgery and ENT to name a few.  Some patients need more specialized examinations than I am trained to do, some need surgery, some need studies or lab work that is best ordered from the office of a specialist.  It is easy to be lulled into a triage mentality when some visits feel like your purpose is to identify and send to the appropriate next step.

Every so often, another physician will consult me, the primary care pediatrician.  At that moment, I realize pediatrics is indeed a specialty with specific knowledge and skills.  Part of my job is to put together pieces of a problem, and to see them as a whole.  So that the patient with juvenile rheumatoid arthritis needs an influenza vaccine when he is on medication that treats his JRA but also compromises his immune system. 

In my 120 bed local hospital, my colleagues look to me and my fellow pediatricians to make recommendations about care of children that effects the entire hospital.  When the call comes in at 2 AM for my opinion, my brain sometimes wants to say “duh, who doesn’t know that?”  By grace and experience, I don’t blurt that out.  Instead, I try to give information that is appropriate, and specialized.  In return, I’m reminded that caring for children takes expertise that I have earned and should use judiciously.

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