Ticked off a Pediatrician

[GetMeOuttaThisMess]

Office manager gets call today from a local pediatrician (don't know them from Adam).  Apparently we send PCP's of patients that we see a copy of the office narrative (wasn't aware of this and it will be stopping).  This guy(?) calls to say that he sees a trend with his patients with usage of cold/cough medication, rescue abx. Rx's, and steroids.  Many of you may know that I'm in a gov't cough/cold clinic that sees kids 2 y/o>.  That being said, I don't give combo cold/cough meds to kids <7 y/o due to AAP recommendations (found a letter online that says 6 y/o from an AAP rep but that's fine).  I am fully aware of no statistical data demonstrating a benefit and I'm also aware of the reported incidences of ED visits due to medication side-effects (actually overdosing of kids though I don't recall a single visit in my 10 years in the ED).  Prednisolone/prednisone studies show statistical benefit for odynophagia in both age populations (dosed at 2 mg/kg/day with my personal max of 20 mg. b.i.d. for 2 days only).  A similar dosing schedule is used to assist with bronchial inflammation from the acidic post-nasal drip induced coughing (we used to use this dosing all the time for croup before current recommendation of just IM'ing them with dexamethasone).  With regard to rescue abx., I follow the AAP recommendation of observation for 48 hours for otalgia and use the Centor scale in lieu of rapid strep screens since sensitivity/specificity is similar.  If it's equivocal on exam then give the steroid for 48 hours and see how the throat does (about a 1/4 to 1/3 will show improvement and/or resolution of odynophagia per JAMA study out of UK 4/17).  I don't have culture capability.  BTW, anyone ever look at the S/S, PPV for your in-office RST or rapid flu's?  If not, you might be surprised.  Detailed, custom written discharge instructions are given to all patients that I wrote using respective specialty guidelines for cough, sinuses, and sore throats which specify if or when the abx. is to be filled.

The only thing that gets my goat about the call was that this individual states, per the office manager, that "we don't use cold/cough medications anymore in pediatrics and if the steroids and antibiotics are continued then I'll have to recommend that my patients go elsewhere and avoid the clinic".  If that is indeed the case I would like to know what they DO recommend since it apparently hasn't made it into the literature aside from nocturnal honey (he DID like this recommendation I give in the patient note), and nasal saline rinse (good luck with a 2 y/o or greater).  I frankly don't give a rip about the steroid tx. and rescue abx. recommendations for specified circumstances (to my knowledge he hasn't see our discharge sheet) since I have discussed this with our SP's on more than one occasion, and we even reviewed the steroid benefit for pharyngitis cases LAST MONTH during our monthly review/discussion.  I haven't heard of anyone being this heavy handed with regard to someone who is treating their patient(s) and blatantly insinuating that they are receiving inappropriate care which is how I am interpreting this based on these comments.  Comments?

[EMEDPA]

do the right thing and if they want to send their pts elsewhere, let them...

[sk732]

Could it possibly be that they're irritated that you're making them better and they don't get to bill for it?

SK

[Guest ral]

I could become a millionaire sitting at home, fielding phone calls from people asking what we are "supposed to do" in any given medical presentation.  We all know it doesn't work that way.  Cookie cutter, algorithmic approaches to every patient doesn't always apply.  Even with the best evidence based practices, each of us knows that you better be on your guard, and we also all fudge a little here or there depending on how the drive into work was this morning.  First, do no harm.  I am out in left field on some of my beliefs, antibiotic resistance being one of those.

[GetMeOuttaThisMess]

The thought has crossed my mind from several different angles.  We're only $10 ("administrative fee") versus a PCP co-pay.  I was just wanting to make certain that there wasn't something overwhelming that I was missing here.  It all seems pretty straight-forward to me.  I think our RN admin is talking with our senior SP today to get his two cents worth.  Since he signs the charts each week he covers, and we've discussed this ad nauseam beforehand, I don't see how there would be a modification in treatment.  Imagine telling all peds patient parents that "You don't need an abx, we don't have effective cough/cold med, your PCP is afraid that we're going to shut down your child's adrenals or cause them to go mad with a short dose of steroid.  Oh, BTW, go home and wrestle with your kid to squirt saline in their nose even though YOU refuse to do same when you get sick as well."

[GetMeOuttaThisMess]

SP says no issue on his end.

[JaxPed]

There are way too many pediatricians out there like UF, 24/7 Pediatrics (www.24hourkidcare.com). and heck, even the Jacksonvlle Hospital system has a good pediatrics center. Your children should be top priority and their care is paramount.