Search for tag: "primary care"

"Should I call the on-call pediatrician?" It's a question you've probably asked yourself when you have a question for your child's doctor and the clinic is closed. I'll help you figure out when it's appropriate to call and when a question can wait until the next office day.

As a pediatrician, we all take call, meaning that we rotate with our colleagues when we answer after-hours phone calls from concerned parents.

Usually, the questions parents have are very appropriate. Sometimes parents are just looking for reassurance that they're doing the right supportive care for their little one. Sometimes they're wanting reassurance that taking their child to urgent care or the emergency room is the right decision and that they're not overreacting. And sometimes they just want to know how much fever reducer to give.

One thing I don't think most parents realize is that the job of the on-call pediatrician is to help determine if their child needs to be seen urgently or not.

We cannot diagnose anything over the phone. Parents will often tell me that they know their child has an ear infection, or strep throat, or a urinary tract infection. I can't tell if your child has any of those over the phone, so they need to be seen.

We absolutely cannot call in medications like controlled substances. We cannot call in medications in general, because if your child needs an urgent medication, they should be seen.

If they need a refill of a long-time medication, that's better to be addressed by your child's pediatrician specifically during office hours. Questions that are not urgent should wait until the clinic is open.

I have one colleague who answers her calls, "Hello, this is the on-call doctor. What is your emergency?" One reason for this is we've gotten questions like, "I'm in the baby food aisle at the store. What food should I get my 6-month-old?" or, "My toddler won't take a nap. What can I do to force them to take one?" or, "How old does my daughter need to be to get her ears pierced?" These are all questions I've gotten.

One thing I've noticed in my years of taking call are that parents often think I'm sitting in the clinic just waiting for their calls. More than once, I've been asked if they can just come in and see me or if I can meet them at the emergency room.

When you call the on-call pediatrician, we are at home with our families. We are not in the office. I've answered phone calls from soccer games, while doing landscaping, when I'm doing hospital rounds in the newborn nursery, when out to eat, and of course, from my bed in the middle of the night.

As pediatricians, we want to be there for you when you have concerns. Kids don't come with instruction manuals, and often things happen when the office is closed. If you have an urgent concern, you are always welcome to call and we will give you the best advice we can. If your concern is not urgent, it will be better handled by your pediatrician during office hours.

Your pediatrician knows your child and your family. They can address non-urgent concerns better than one of us who has never met your child before.

Interviewer: It's a very common medical complaint that doctors get, dizziness. What does it mean and what can you do about it? We'll talk about that next on The Scope.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists" with Dr. Tom Miller is on The Scope.

Interviewer: We're with Dr. Tom Miller, and we're going to talk about when a patient comes to him with a complaint of dizziness. What does that mean, and what can you do about it? So I come to you, I'm saying, you know, I've been feeling dizzy lately. What do you do at that point?

Dr. Miller: That's a really good question. And dizziness is one of the most common complaints that we get in primary care clinics. And basically, you have to break it down, because dizziness is just a non-specific term that means anything from fuzziness in the head to spinning to lightheadedness when you stand up.

Interviewer: All right. I'm assuming since you have to break it down, there'd be different ways that you'd handle the specific symptoms.

Dr. Miller: Right. So as soon as the patient says, "I feel dizzy," then you start to ask questions that are modifiers to how you're going to approach this problem. So, basically, one of the questions I ask, I ask them to describe dizziness. And so they'll say, "I feel lightheaded when I stand up, or I feel lightheaded when I'm getting up out of bed. I get a fuzzy feeling. I start to lose vision, or I feel like I might pass out." That's one type. The other type is, "Do you have the sensation of spinning?" which is vertigo. And that's a very specific type of dizziness, spinning. The room is spinning. You're spinning. You're moving in space. That's very different than a lightheaded feeling or sensation.

Interviewer: So if it's a lightheaded feeling and sensation, what does that mean for the patient?

Dr. Miller: Well, sometimes, it just . . . You know, this can happen in well-trained athletes. So imagine that you go out on a hot day and you run about four miles. You come back, and you're a little bit dehydrated. Your blood vessels are dilated. You sit down on the couch, you begin to watch your favorite sports show on TV, the phone rings and you jump up to get the phone, and whoa, you get wobbly. You start to lose vision. Basically, what happens there is your blood pressure dips, and you're not getting enough blood to the brain, and you start to pass out. That's a type of dizziness that causes lightheadedness.

Interviewer: Okay, that's sounds scary.

Dr. Miller: Basically, that's due to low blood pressure. It's not really scary. I mean, basically, with a couple of . . . First of all, you need to hydrate when you get home, right? Now, sometimes, it can be in people who do have problems like heart disease, or they're on antihypertensives or blood pressure medication that lower their blood pressures to a point that when they stand up and move around, they become they too light. They become to the point where they don't think they're going to stay awake. They're going to fall down. They start to lose vision. Their vision dims. Maybe they're hearing starts to disappear. And it's just this sense that they're going to go down. And so, basically, in that situation, you want to crouch down, and it pushes all that blood back up into your head. So you get down, you crouch down, and then the blood returns, and you're going to be okay.

Interviewer: Like put your head between your legs, crouch down sort of a posture?

Dr. Miller: Yeah, exactly.

Interviewer: What does that look like exactly?

Dr. Miller: Well, actually, probably the best way, if you can handle it, is to squat down. Squatting pushes blood back up into your cardiovascular system and drives blood into your brain, so that . . .

Interviewer: Staying in an upright position when you squat down? Okay.

Dr. Miller: You just squat down. Or if you really feel like you're going to pass out, you lie down.

Interviewer: Okay.

Dr. Miller: All right. And then some people get into a hot tub. They might have a half a glass of wine. They get out of the hot tub, they're relaxed. Boom, they have that sensation. That's pretty common. Basically, as soon as you sense that, and some people for reasons we don't quite understand, are just sensitive to those types of environments where, you know, they're . . . after exercise, or they're coming out of a hot tub, they might get very lightheaded when they stand up. So squatting down immediately is a way to remedy that or lying down will get the blood back to the head and resolve that problem.

Now, in the future, you have to prevent it. And to prevent it, you have to stay well hydrated. You have to be aware of the situations that create this sort of lightheadedness. So that is, again, you know, if you're exercising on a hot day and you relax, you have to realize that you need to hydrate. Also for people who are taking blood pressure medications, they need to be very aware of the situations in which they can become lightheaded, because you don't want to get to the point where you actually pass out or hurt yourself and that happens. That does happen.

Interviewer: Yeah, sure. Because that . . . It's not actually the lightheadedness that's causing the problems, it's what happens after you pass out. Right. Yeah.

Dr. Miller: Yeah, you hit your head and you really have a problem. So, you know, also think about people who are getting up in the middle of the night to go to the bathroom and they get lightheaded. It's dark. They trip, fall, and hurt themselves.

Interviewer: But otherwise, it sounds like the lightheaded type of dizziness is not, in of itself, something scary. You just need to be aware of what's causing it, try to do things to prevent it. If you feel that way, crouch down, try to get that blood back to the brain, and you're good.

Dr. Miller: In a majority of situations. Now, if you're on blood pressure medications, you may be on too high of a dose. You may need to go back to your physician and have your doses adjusted or your reason for taking those medications re-evaluated. Certainly, if you have heart failure, that is a whole 'nother issue. That's sort of beyond the scope of this discussion.

Interviewer: Gotcha. But as a general rule, that lightheaded type of dizziness, in of itself . . .

Dr. Miller: If you're aware of it and you know what you need to do immediately is get down to ground. Squat down or lie down and get your feet up.

Interviewer: Gotcha. What about the spinning kind now?

Dr. Miller: That's vertigo. Vertigo is a sensation of spinning or turning in space. It's that sensation we get when we spin around on a chair, or we turn around and around and around as little kids, you know.

Interviewer: It's been a long time since I've done that because I don't like that feeling.

Dr. Miller: Well, you could be on a fun ride at an arcade somewhere and you have that same sensation. So, basically, that is a sensation that occurs because of changes in the inner ear. So the semicircular canals, which direct sensation and position in space, have this abnormal input. And when that happens, you get the sensation of spinning. You might actually be spinning. And when you stop, you still have the sensation that you're spinning, or it may occur for other reasons.

Now, the most common reason or one of the most common reasons that people get vertigo without actually spinning around in a circle is something called benign paroxysmal positional vertigo. And this occurs as . . . in many people as, not many, in some people as we get older, where you have these little tiny particles break loose and rattle around in the semicircular canals. And what those little particles do is they bang on the hair cells that sense your position in space, and they send this very aberrant signal. And all of a sudden, you have this very strong sensation that you're spinning and turning when you're actually standing still.

Usually, this common cause of vertigo, benign positional vertigo, occurs when you roll over in bed, or you bend over to pick up a shoe, or you look up at a cabinet and try to take a cup out of the cabinet, and all of a sudden, you'll just have this incredible intense spinning sensation that lasts maybe 10 to 15 seconds. And it's reproducible usually by doing that same maneuver. Now, people when they come in and complain of this, they think they're dying, or they're having a stroke. And so it's our job to sort out whether it is temporary as it is in this benign positional vertigo. And if it is, it's likely due to this little particle that's banging around in the inner ear. And there's treatment for that. It's actually physical therapy.

Interviewer: Okay.

Dr. Miller: You could do a maneuver, and usually the maneuver will help put those little particles back where they belong . . .

Interviewer: Really?

Dr. Miller: . . . and then, you're okay. You're on your way. In some cases, if it's worse, we send them to an ear, nose, and throat specialist, and they do their special work, and that takes care of it.

Interviewer: Just want to make sure that I understand. So the lightheaded type of dizziness, unless you're on some sort of medications, sounds like it's not necessarily something you need to mention to your doctor?

Dr. Miller: You can if it's recurrent. I mean, obviously, if you're having situations where it's occurring more frequently and it didn't occur before, that's something you probably should see the physician about.

Interviewer: And the spinning type?

Dr. Miller: The spinning type is something that most people will seek attention for because it's so intense. And you know, if it's bad enough, it'll cause you to throw up. And it's so abnormal and unusual that people seek care for that.

Interviewer: Gotcha.

Dr. Miller: And there is treatment. There's treatment. There are less common causes of vertigo, viral causes where you just all of a sudden have intense spinning sensation and you're sick for three or four days and you're bedridden and sometimes hospitalized because you can't keep any food or fluids down. And that eventually resolves.

Interviewer: Gotcha. So in both of these . . .

Dr. Miller: Sometimes, even more rarely, it would be a stroke.

Interviewer: In both of these instances, perhaps talk to your primary care physician if it's becoming something that happens a lot?

Dr. Miller: Right.

Interviewer: And you know, not only for your quality of life but your peace of mind. But as a general rule, neither one of these two things sounds too threatening?

Dr. Miller: Not too threatening, but can be pretty scary if you haven't had them occur before. And I would think that most people from time to time have experienced the lightheaded kind of dizziness, and they usually will figure out what causes that. It's usually getting up too quickly.

Announcer: Have a question about a medical procedure. Want to learn more about a health condition. With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Dr. Gellner: Parents know they want a good doctor for their child, but how should they go about actually choosing a pediatrician? I'll give you some pointers on how to find the best kid doc for your child on today's Scope.

Announcer: Keep your kids healthy and happy. You are now entering the "Healthy Kids Zone" with Dr. Cindy Gellner on The Scope.

Dr. Gellner: As a parent, we all want the best for our children, so when you go to find a new pediatrician, whether you're still expecting your first baby, have an insurance change, or move to a new city, finding someone to care for your child's health is a huge decision. Just like any other long-term relationship, you need to be comfortable with the person you are entrusting your child to. So how do you find a new pediatrician?

First, talk to your friends who have kids. I know a lot of my patients come to me and the parents say, "Oh, you see my neighbor's child," or, "You see my nieces and nephews," and they all said, "I just had to bring my kids to you."

If you are just changing insurances, ask your current pediatrician who they would recommend. Often we know the other docs in the area and who would be a good fit for your family.

Another good tip is to check out the American Academy of Pediatrics' website and use the "Find a Pediatrician" tool. It will help you find a board-certified pediatrician in your area, and then you can search that provider on various patient satisfaction websites to see what others think of that pediatrician.

Many practices actually have their own websites that answer a lot of questions for you. Often, you can look at each pediatrician's profile to see when and where they did their medical school and residency training, do they have any specific areas or interests, what are the clinic's office hours, and who takes care of any concerns when the pediatrician isn't in the office. And don't forget about looking to see what insurances the practice accepts.

Some parents choose to do a meet-and-greet appointment with a prospective pediatrician. You'd have to call to see if the provider does those types of visits and if a co-pay is required. You can then check out the office to see if the staff is comfortable with kids, is the facility kid-friendly, and does the pediatrician seem down-to-earth, easy to talk to, knowledgeable, and like they really enjoy working with the little ones.

Can your child be seen the same day for sick visits? Who covers for the pediatrician after hours? Does the pediatrician go to any hospitals? Usually, we know what information parents want when they come in for these types of visits, and so we can help you make sure you're not forgetting anything to ask.

Bottom line is you should feel absolutely comfortable with your pediatrician and feel like you can trust them to have your child's best interests at heart. If the fit doesn't feel right, move on until you find the best possible pediatrician for your family.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Parents know to take their child to the pediatrician when they're sick. But why is it important for kids to continue to get an annual well-child visit checkup even when they appear healthy?

Quite often when I tell parents their child is overdue for a well visit, parents are like, "But my kid is healthy and isn't due for shots. So why do they need a well visit?" Well, why do you need an annual physical? A well visit for kids is just like an annual physical for adults but so much more.

During a well-child visit, your pediatrician will review how your child is growing. Are they on track? Are they overweight? Are they underweight? Are they due for any vaccines you may not have realized they're due for? How are they eating, sleeping, getting along with others in the family, their peers? Is the home a safe place, or are there red flags for childproofing or violence that we need to address?

At ages 18 and 24 months, we screen for autism. During their infant and early childhood years, we ask screening questions about their development as well to make sure they are meeting their milestones. Starting at age 12, we screen for safety, depression, sexuality issues, and substance use. These visits also reinforce to your child the need to keep on top of their healthcare needs by helping to establish a good relationship with your child's doctor and show how even when they're doing well, it's important to keep regular appointments for preventive care.

Just a heads up though. While you may want to save a bunch of your questions about acute or chronic needs that your child has for their well visit, your pediatrician will probably ask you to schedule another appointment to address those. We realize it can be inconvenient, but appointments are given a certain amount of time, and we do not want to rush through your concerns because of time limitations. Asking you to schedule another appointment will make sure that we're able to thoroughly address all of your concerns.

Another reason you may be asked for a separate appointment is that a well-child visit is a preventive visit and it is billed as such. Insurance companies often do not charge for a co-pay for a preventive visit. Acute or chronic issues, medication refills, and follow-up visits are billed differently. Insurance companies do not like when the two are combined. And you will either get a separate co-pay if you have private insurance, or Medicaid could deny the charges if your child is Medicaid.

In short, well-child visits can help make sure your child is on the right track to being and staying healthy. For other concerns, be sure to schedule appointments as needed with your child's pediatrician.

updated: July 6, 2020
originally published: August 13, 2018

Interviewer: Three things patients should ask and three things all doctors should be sure their patients understand. That's coming up next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Sometimes as a patient when you're in clinic with a physician, you leave and you're like, "I don't know what's wrong with me and I don't know what to do about it," and you're just confused. But if you ask these three questions, and if you're a provider you make sure patients understand the answers to these three questions you could solve all the problems. We're going to find out more about the Ask 3 Program. Darren Doman, he's the Patient Education Specialist here at University of Utah Health Care. What is the Ask 3 Program and it sounds magical?

Doman: It is pretty magical. It's an initiative put together by the National Patient Safety Foundation and it's meant to just help improve communication between health care providers and their patients in efforts to improve health outcomes. So basically they synthesize every visit into three main questions.

Interviewer: Okay.

Doman: First, "What is my main problem?"

Interviewer: Yeah okay.

Doman: That's a good question.

Interviewer: That's a great question. That's why you're there.

Doman: Exactly.

Interviewer: Yeah.

Doman: Put a label on it, give it a name. The second question is, "What do I need to do about it?" And then the third question is, "Why is it important for me to do that?"

Interviewer: I love that because I think it synthesizes in very, three very quick little questions. Like when you're a patient you leave and you don't understand what just happened and you're trying to figure out, "What could I have done to change it?" I think this is perfect.

Doman: Absolutely and there's some research out of Great Britain that shows that when it comes to an outpatient doctor patient interaction, 80% of people leave that visit without accurately recalling any information that the doctor told them.

Interviewer: So it would be hard for them to tell their husband, their wife, their kids, anybody.

Doman: Exactly, but when they probed the 20% that remembered something a little bit closer, only half of them actually got it right.

Interviewer: Really?

Doman: So it's really 9 out of 10 people leave the doctor's office not able to remember accurately what the doctor told them.

Interviewer: That's pretty incredible and that's based on research.

Doman: Based on research out of the UK.

Interviewer: All right so the Ask 3 Program, "What's my main problem?" "What do I need to do?" "Why is it important for me to do this?" Is there any research on showing if people ask these questions what retention rates are?

Doman: Well the most current research that I read was showing that patients aren't actually asking these three questions.

Interviewer: Okay.

Doman: So we need to take a step back, revamp the program, and maybe think about it a little bit differently. Which I think is a perfect opportunity for us to talk to providers and say, "You know, here's three great questions. If your patients aren't asking these questions, why don't you just help them out and give them this information?"

Interviewer: Yeah just make sure that they understand these three things.

Doman: Exactly and that speaks to the need for open communication between patients and doctors to really get the message home. Patients need to be asking the questions, doctors need to be telling the patients the right things, and they need to be checking to make sure that the message was received.

Interviewer: So it sounds like a good idea as a patient if I go in that maybe when it starts getting a little confusing I just need to fall back on those three, you know? Because sometimes the issues get a little muddled right?

Doman: Absolutely, and just bring it back to, "Okay what's the main problem?"

Interviewer: "What do I need to do?"

Doman: And, "Why is it important to do it?"

Interviewer: And as a provider it might be a good idea after you tell them these three things to ask them, "Okay do you understand what your problem is? Tell me what it is." When I was in my communication classes that's all part of listening, it's all part of checking to make sure the person understand what you just said to them is to ask them to tell you what you just said to them.

Doman: Absolutely and providers who are really keyed into this can do it very artfully. They can say, "I think your main problem is this," and then, "Later when you get home what are you going to tell your spouse that your main problem is?" Just to check and see.

Interviewer: Yeah, because a lot of times we assume that the person understood us and we don't want to insult their intelligence by insinuating on some level that they didn't, but a lot of times people don't. I mean there's a lot of a thing that can go wrong with communication, it's not either individuals fault.

Doman: It's true, and double checking message received is never a bad idea.

Interviewer: What's keeping patients from asking these three questions do you think?

Doman: When it comes to patients asking questions in doctors' visits I always think its fear based. They don't want to look stupid in front of their care provider. Maybe they kind of know the answer but they're a little bit afraid of actually hearing somebody else say it. So there are reasons why they might not pipe up and actually ask.

Interviewer: But at that point it's important beyond your ego, beyond anything else, to clearly understand what's going on, what you need to do, and how important it is.

Doman: Sure, yeah.

Interviewer: And how about physicians, is there a barrier to them adopting kind of just these three questions making sure patients identify it? Is it something they ever thought about before?

Doman: I think it takes that moment of just engaging your brain and checking in rather than getting into too much of a routine. Everybody kind of gets their routine going, they kind of do it the same way they've always done it, in and out, keep the flow going. But if we can actually engage with the patients say, "Here's my new routine, here are these three important things that I need every patient to understand," I think we're going to have a better go of patient interaction, better communication, and ultimately better health outcomes.

Interviewer: Any final thoughts on the Ask 3 Program? I think it's brilliant.

Doman: I think its brilliant too, and just getting the word out to patients and providers alike that it's a conversation. It shouldn't be one-sided doctor talking all the time. The patient should have some input as well and if the patient doesn't know quite what to ask here's three good questions. Anybody who asks these isn't going to look stupid in front of their doctor.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook, just click on the Facebook icon at TheScopeRadio.com.

Pediatrics is generally a very happy specialty. When it's sad it's a very sad specialty. I think pediatricians bond together for that reason. You know, I've heard people say they can't even walk into the children's hospital. It's too hard, it's too depressing. To me it's a wonderful place filled with hope.

Working with children is difficult because devices, medications, vaccines are all tested on adults. You're always going to be relying on adult studies and children are not just small adults.

About 10% of all infants in the first 90 days will have a fever. It's a really vexing problem especially for young infants. Because any fever could represent a very serious infection you have one chance in the emergency room to get it right. Do you admit them or do you send them home? And you want to make the right choice.

The current recommendation is all of those infants have medical care and that the majority of them would be hospitalized. But that's hundreds of thousands of admissions each year. It's incredibly costly, in the billions of dollars.

For the last 15 years or so, all of my time here at the University of Utah, I have focused on the development and implementation of something we call the Evidence Based Care Process Model. Using input from laboratory staff, nursing staff, administrators and parents we built a care process model that we could all say, "This represents the best possible care that we could give in our system".

We started small with one virus and now we have technology where we can diagnose 15 viruses, we can diagnose bacteria in under an hour. It's now routine in hundreds of hospitals around the country including many children's hospitals. And so being able to go to a parent and say, "I know why your baby has a fever," that is such a relief. And that's where the joy of it is and that's where the benefit of it is. You know that kids are better off not just here but in other places because you did the research.

I took care of adolescent leukemia patients for eight years. And that's a really difficult thing to do. I cannot tell you that it was less difficult for me on the last day than it was on the first day.

I was taught that gradually you become less sensitive to the patient situation if you take care of patients in desperate situations. I found that to be totally untrue.

The purpose of healthcare is to make a person as healthy as possible. And if that is perfect health, great. There are times in people's lives when that's no longer possible, but to keep them at their highest functioning level, and as happy as they can be for as long as possible. The goal of health care is not just to do that, but to find out what that means for the patient, and do that.

I see all of these things as an opportunity, and how do we take the situation we're in, and help turn it into something that's really great. When we talk about patient experience for example, the patient has a head injury doesn't think of patient experience in the same way as a mother who has just given birth. You can't have a formula for the whole hospital. Everybody does it differently.

What we do here at nursing is we have the right people, and that's not easy. We have to hire people who've got a passion for what they're doing.

We started out with a top down approach, and of course that doesn't work, and I know that doesn't work. So what we said was you take care of patients everyday, you know what your patients need, and I know that you want to make the best possible care that we can for them. Tell me what the barriers are, and my job is to remove the barriers so that you can provide that kind of care for your patient everyday.

I don't dictate anything. I don't tell people what they have to do. I tell them what the goal is, I try to inspire them that the goal is worthy, and then I ask them to think through what's the best option for their staff, and their patients. Then that's how we get all of our innovation.

Most of the things that we do, I had no idea that that's the way it's going to come out. I'm always thrilled to death to see what they come up with. They come up with some fabulous ideas that I never would have thought of. It's imperative that the patient is at the front of all of our conversations. It's all for the patient.

What we have to confront in our own nation is: Do we have a national commitment to funding research to improve health?

Well, imagine if we have a population that's not healthy, that doesn't have access to the best care that science underpinned. Imagine that absent science we have no idea what works best for whom, in what context, and why.

So how can we confront those challenges? The power of science brings an evidence base to that that really separates it from unguarded or unfounded opinion. So once we have the power of science, we can think about health in terms of improving the health of an individual patient but also of that patient's family, of the community, and the population, many of whom are vulnerable. And I think once we talk about reframing that for innovation as to improving health through all of those, then some of our other challenges may fall away.