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How to Get What You Want from the Pediatrician

Doctor, Teacher, Therapist, Friend
Pediatrics is probably the happiest branch of medicine. Medical students choose it because they love children, and most seasoned pediatricians will tell you that the joy of working with youngsters still holds up 30 years into their careers. In addition to being cute and generally endearing, children tend to recover quickly and come down with serious illnesses far less often than adults. If doctors like to succeed, the chances of doing so are much greater in pediatrics than in any other field of medicine. Perhaps because of this, 69 percent of all medical residents plan on becoming pediatricians. What this means for parents is that there are a lot of enthusiastic, talented pediatricians who would love to serve your family.

Behind the Scenes: Multitasking and Loving It
Children's health care used to be about treating severe communicable diseases such as polio, scarlet fever, diphtheria, and smallpox. All that changed during the last half of the twentieth century, when vaccinations for most of these diseases were developed. Today, health issues are only a part of the pediatrician's territory. "So much of what we do is, for lack of a better term, social work/ mental health care," says Margaret Fitzgerald, a family nurse practitioner in Lawrence, Massachusetts, and founder of Fitzgerald Health Education Associates. Parents count on pediatricians not just for health matters but also for advice about discipline, learning disabilities, social problems, sibling rivalry, custody conflicts, and much more. Writer and pediatrician Perri Klass notes that "parents these days often look to pediatricians to provide the sort of expertise that once was given by a resident grandparent or neighboring aunt." While an adult wouldn't dream of asking her doctor how to solve a problem she was having at work, parents rely on pediatricians to help them solve problems with school bullies, homework, testing anxiety, and a whole range of other school issues. Guidance counselor, grandma, physician, behavioral therapist, and education specialist – today's pediatrician is expected to fill all these roles, and for the most part she cheerfully complies.

Parents aren't the only ones who expect a lot out of pediatricians. The police expect them to be on the lookout for physical and sexual abuse. Schools expect them to help educate teenagers about substance abuse and sex. The American Academy of Pediatrics expects them to provide "anticipatory guidance" for parents, which means informing them about every conceivable childhood safety issue, including but not limited to seat belts, bike helmets, sleep position, nonflammable pajamas, scooters, drowning, lead screening, gun safety, television viewing, and of course, sex, drugs, and smoking. Finally, pediatricians are under pressure from HMOs and insurance companies to provide rapid, cost-effective services. The typical pediatrician sees 28 children a day; the average yearly checkup lasts 15-20 minutes, and a sick-child visit lasts 10.

Despite all the demands, pediatricians are for the most part a willing and passionate group. They readily acknowledge that they aren't just treating children, they are treating families, and they seem eager to step up to the plate even though medical school rarely prepares them for the challenge. Says pediatrician Andrew Baumel of Framingham, Massachusetts: "Training in mental health is definitely deficient. You learn a lot on the job." Most of that learning has to do with how to talk to parents. Baumel's biggest surprise when he became a pediatrician was that "everyone has an advocate. In other areas of medicine, you're dealing with one person who has a problem, but in pediatrics we always have two people for every issue: the patient, who is frequently over two and verbal, and the parent, stepparent, grandparent, et cetera. So we're always dealing with at least two people, and sometimes four or five." Twenty years ago, doctors often resented parents who asked too many questions. Today, everyone agrees that children's health is a family affair, and for pediatricians that means knowing how to talk – and listen – to parents. More than other doctors, they welcome your input and are tolerant of your anxieties.

However, even the most virtuous pediatricians can be pushed to their limits by overly demanding, careless, or inconsiderate parents. And because pediatricians receive the same basic medical training as all doctors, they have some of the same biases: they value calm voices, clarity, and facts, and are turned off by too much emotion and vague information. (First-time mothers get a free pass on neurotic overworrying and general cluelessness until the child is about two; then most pediatricians expect them to calm down.) To get the best out of your pediatrician, begin by learning the basics they wish every parent understood.

What Pediatricians Really Want You to Know
There are plenty of things pediatricians would like parents to do and say while they are in the office, and we'll get to those shortly, but there are also a few key concepts they wish all parents were clear on before they called or scheduled an appointment.

Vaccinations are safe. Unbelievably, pediatricians now have to sell some parents on the benefits of vaccines! In the late 1990s a wave of suspicion about vaccines began to spread across North America and Europe, fueled by rumors that they could cause autism, attention deficit disorder, diabetes, fever seizures, polio, and even AIDS. Ignorance about the diseases themselves compounded the problem. A study done in 2001 found that 90 percent of parents of school-age children didn't know that chicken pox can have deadly complications. Half of those parents said they would rather their kids catch the disease than vaccinate them against it.

Pediatricians were aghast at these developments. Fortunately, new studies confirm the safety of most vaccines, including those protecting children from measles, mumps, rubella, hepatitis B, diphtheria, and polio. The chicken pox vaccine is relatively new so there are no long-term studies of it, but it is recommended by the American Academy of Pediatrics, and studies done thus far show the vaccine to be safe and effective for most children. If you have any doubt at all about vaccinating your child, ask your pediatrician for the most recent information.

Antibiotics don't cure everything. Doctors themselves are partly to blame for parents' love affair with antibiotics, since they are the ones who have prescribed them too often in the past, sometimes just to keep parents pacified. In a recent study, one-third of the pediatricians surveyed admitted to caving in to parents' demands for antibiotics whether or not they were called for. As a result, some strains of bacteria are becoming resistant to antibiotics – a very alarming development.

Antibiotics are only effective against bacterial infections. They cannot cure colds and flu, which are caused by viruses. However, colds and flu sometimes develop into bacterial infections, in which case antibiotics can help. It's a tough call to make, and that's what the pediatrician is there for. As a general rule, antibiotics can cure strep throat, some ear infections, some cases of chronic coughs or bronchitis, and some severe sinus infections lasting longer than two weeks. Antibiotics cannot cure most sore throats and most coughs.

Fevers are good. Pediatrician Andrew Baumel's views about fever are shared by the overwhelming majority of doctors: "Fever helps the body fight infection. Our immune system works better and quicker at a higher temperature. For a low-grade fever of 100° or 101° , you don't have to use antifever medication, depending on whether or not the child is uncomfortable."

Fever is a symptom, not an illness. A fever can get higher if an illness gets worse, but it won't rise just because you don't treat it. Brain damage can occur only if a fever reaches 107.6° F and stays there for an extended period of time. Untreated fevers usually peak at around 105° unless the child is in a hot room or overdressed.

Infants do need special handling when it comes to fevers. If they are younger than 60 days old, any fever of 100.4° or higher signals the need for a visit to the doctor. From 60 days to three years of age, call the doctor if the fever is 102° or greater. In infants and young children, low-grade fevers that have no obvious source can be a sign of serious bacterial infection. Febrile seizures (convulsions that are brought on by fever) can occur in children whose temperatures rise rapidly. The number itself doesn't matter so much as the speed at which the temperature rises. Although they are frightening for parents, febrile seizures are brief and have no lasting effect on the child.

For children older than two years, call the doctor any time a fever is 105° or greater. Call the doctor after 48 hours about a fever of less than 105° if your child seems healthy and active – an infection could be brewing. If she has cold or flu symptoms, you can wait 72 hours to call. If she is uncomfortable, vomiting, dehydrated, or having problems sleeping and the fever is less than 105°, try to lower it – but only to 100° or 101°, so that it can still fight the infection.

Sick children need to take all their medicine. One unnerving development in this age of miracle drugs is that parents frequently do not bother to follow through on the regimen. For instance, instead of receiving the complete 10-day course of penicillin for treatment of strep infections, 56 percent of children do not receive the drug by day three, and 71 percent don't receive it by day six. Often this is because the parent either doesn't believe it's really important to follow through or doesn't understand the directions. Doctors want parents to realize that if a child does not take the complete cycle of a medication, the original condition may come back stronger than before. If you are confused about administering the medicine but feel foolish asking the doctor to repeat the instructions, talk to the nurse. You are not alone; many people find the directions confusing.

Your child's health care depends on what you tell the doctor. "Ninety percent of our diagnosis is made by the history, by just talking. Ten percent is made by physical exam and lab studies," says Andrew Baumel. Parents, then, aren't just advocates in the pediatrician's office; their observations are the raw data doctors rely on most to treat children.

Yet even the most devoted parents are sometimes reluctant to be forthcoming with the pediatrician, for many of the same reasons adults cite. They may be embarrassed by a problem their child is having or afraid of what the doctor will discover. Many parents become distracted during the visit and forget to relate the most important information. Some don't want to appear ignorant, while others don't want to take up too much of the doctor's time.

It may be tempting to think that a really good pediatrician will uncover any serious problem with your child whether or not you are forthcoming. That is not how pediatricians view things. Good doctors will take a comprehensive history during the yearly checkup, but ultimately they depend on you to tell them anything you think might be relevant to your child's well-being.

Magic Words and Deeds in the Pediatrician's Office
The well-child checkup is where your most in-depth conversations with the pediatrician will take place. The best time to schedule one is April through September, on any day other than Monday. October through March is flu season, and Mondays are loaded with kids who got sick over the weekend. Parents tend to schedule a yearly checkup around the child's birthday because it's easy to remember, but that is not necessary. You will get a more relaxed doctor and possibly more time if you schedule during the slow months. If you want an extra-long visit or have special issues to discuss, ask the front office if taking the last appointment of the day will assure you more time.

Before your visit, take a few moments to think about your child's health, behavior, and development. Pediatricians expect you to report anything out of the ordinary, even if it doesn't seem to relate to health care. For instance, a child who suddenly starts getting into trouble in school and whose work takes a nosedive may be having social problems, but it's also possible that he is having difficulty with his vision or hearing.

Next, prepare a list of topics you wish to discuss with the doctor – and be sure to prioritize them. With only twenty minutes for the average visit, you may not get to discuss everything. Be sure to take paper and pencil along to jot down the doctor's advice. The Merck Manual reports that within 15 minutes after an office visit, some parents have already forgotten half the information. Parents tend to recall the first third of the visit best, and to remember more about diagnosis than treatment.

Doctors will usually run through a series of questions relating to your child's health and development, and of course you should answer these as specifically and clearly as you can. Keep your list of topics handy so you won't forget your own agenda when the doctor starts talking. For a smooth, satisfying office visit:

Get your child undressed before the exam, if you are so asked. Lots of kids resist taking their clothes off, so their parents wait until the doctor comes in to start wrestling with them. This is a waste of time and a major irritant to doctors. "Skin can tell you so much about what's going on," says Andrew Baumel. "The child really needs to be undressed to be examined properly."

Greet the doctor as if she is an old friend. It will put your child at ease, particularly if she sees the doctor infrequently. If the doc doesn't greet your child by name (a good doctor will), casually reintroduce them: "Chloe's grown a lot since last time, Dr. Harmon." Your friendliness toward the doctor signals confidence in her, which will make your child more cooperative.

Keep your tone of voice calm and cheerful. If your voice is important when you visit your own doctor, it is doubly so at the pediatrician's office. "The child picks up all the parent's cues," says Baumel. "When parents are nervous, the child feeds off it. Parents can make the child much, much more anxious than he would be on his own." Your tone is more important than the words you say, so if you can't keep the anxiety out of your voice, say nothing at all.

Ask the pediatrician what she will be doing during the exam. This is for your child's peace of mind. Sometimes the doctor will volunteer the information, but often they just start right in questioning you or examining your child.

Tell the pediatrician good news as well as bad. Progress is just as important as problems in helping the doctor assess your child's development. If your son is getting along better with his older brother, excelling at reading, or playing an instrument, let the doctor know. It provides a more balanced view than when you simply list all the problem areas.

Separate fact and opinion, and be specific. When describing problems, make a distinction between your worries and what has actually taken place. For example, say, "I'm concerned that Cindy may be backsliding in her toilet training. She has an accident about once a week," not, "Cindy's backsliding on her toilet training – she has accidents all the time."

Bring help if you're bringing other kids. If it's noisy, the doctor will not be able to give his full attention to the child who is there for the checkup. She needs to listen to the heart and lungs, talk to you without interruptions, and focus on your child. You need to focus on the child, too. It's best if only the two of you are in the examining room.

Stay calm and steady during shots. Your attitude will keep the tension low and help your child deal with the pain. Do not apologize, grimace, or in any way indicate that there is a choice about this procedure. You can be mildly sympathetic, but the moment you start looking anxious your child will get even more upset. If the child really puts up a struggle, follow the nurse's directions to restrain him, and be kind but firm. After the shot, thank the nurse, hug your child, and congratulate him on a job well done. That's the end of it – no big deal.

Absolute No-No's
Pediatricians are very consistent about what annoys them in the examining room. That's because they hear the same irritating comments from parents day in and day out. Avoid these and your doctor will love you for it.

Don't use the doctor as a threat. Says Andrew Baumel, "Every day I hear, 'You better be good or he's going to give you a shot.' What message does that send? You're putting up more barriers."

Don't talk to the pediatrician when she has the stethoscope on. She can't hear you, so she's not going to answer. If you speak loudly, she can't hear the heartbeat.

Don't try to squeeze a general checkup into a sick-child visit. The doctor probably won't do it, and even if he did, you would be getting a rushed, substandard checkup.

Don't try to piggyback one child onto another child's visit. With an average of 28 patients a day, the pediatrician's schedule is usually very tight. They dislike being pressured into seeing children they have not made time for.

Don't diagnose the problem for the doctor. You may be correct, but it's best to phrase it as a suspicion rather than as a foregone conclusion. Rather than announcing, "Brenda has strep again; she needs more Augmentin," say "Brenda seems to have the same symptoms she did last time she had strep," and let the doctor take it from there.

Don't be rude to the person at the front desk. It will get back to the doctor, the nurse practitioner, and the rest of the staff, and they will think less of you no matter how well-behaved you are with the doctor. If you want these people on your side when an emergency comes up, be nice to them now.

Covert Operations
As children grow older and less likely to confide in Mom and Dad, parents often turn to pediatricians for help in ferreting out the details of their lives. They routinely ask pediatricians to test their teenagers for drugs or sexually transmitted diseases, or to confirm that their daughters are still virgins. "I won't do it," states Margaret Fitzgerald about the latter issue. "It is truly impossible to tell. It's unfair because there's this assumption that you could examine a girl and say yes or no, but there's no expectation that you would examine a young man and come up with an answer." Fitzgerald also refuses to test for drugs or STDs without the adolescent's permission.

Confidential care for minors is a slippery slope for health-care providers. Each state has its own laws as to what kind of information about an adolescent can be kept confidential from a parent, and under what circumstances. The Allan Guttmacher Institute Web site, at www.agi-usa.org, lists confidentiality laws by state. But even if it were legal to attain details about your child's life without the child's knowledge, many pediatricians would be reluctant to cross that line. "I will use the issue as a way of facilitating a dialogue between the child and the parent," says Fitzgerald. She offers this somewhat world-weary observation for parents concerned about their teenagers' sex lives: "The idea of two fifteen-year-olds having sex does not warm my heart, but at least in all likelihood they're equally unempowered. It is more likely not to be an exploitative relationship at that age. Fourteen- and fifteen-year-old girls are rarely pregnant by fourteen- and fifteen-year-old boys. Usually it's by twenty-one- to twenty-five-year-old men."

Bidding Farewell to the Exam Room
When your child is eleven or twelve years old, it's time to introduce the idea of seeing the doctor alone. "Part of growing up into a young adult is the kid's responsibility to participate in his or her own health care," says Fitzgerald. "I generally start saying that to parents and children at an age when you couldn't surgically extract the parents from the exam room. The child wants the parent there, the parent wants to be there." When the children are twelve or thirteen, Fitzgerald will ask the child if she wants the parent to stay or leave. By the age of sixteen, a child should definitely be accustomed to going it solo at the doctor's office. The sooner they learn how to talk to effectively communicate with the doctor, the better.