Acebecker Posted March 9, 2012 Author Share Posted March 9, 2012 All - I have a dilemma I'd like input on. My family has been going to the same physician for years - he's been my kids' doctor since birth. He is a family friend. However, I have begun to see some things I'm less than thrilled about. Without going into details, I have questioned his judgement and thoroughness. I know I have less experience than he does and it's his license on the line, but it's the health of my children. Should I switch to a doc or mid-level who will be more thorough? Or am I abusing the relationship I have with the doc and imputing my will/diagnosis on him? My wife got home today and asked (after he'd outright rejected a possible diagnosis and the notion of testing for it) if he might be trying to get us to leave his practice... Thoughts? Andrew Link to comment Share on other sites More sharing options...
Acebecker Posted March 9, 2012 Share Posted March 9, 2012 All - I have a dilemma I'd like input on. My family has been going to the same physician for years - he's been my kids' doctor since birth. He is a family friend. However, I have begun to see some things I'm less than thrilled about. Without going into details, I have questioned his judgement and thoroughness. I know I have less experience than he does and it's his license on the line, but it's the health of my children. Should I switch to a doc or mid-level who will be more thorough? Or am I abusing the relationship I have with the doc and imputing my will/diagnosis on him? My wife got home today and asked (after he'd outright rejected a possible diagnosis and the notion of testing for it) if he might be trying to get us to leave his practice... Thoughts? Andrew Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 9, 2012 Administrator Share Posted March 9, 2012 In my relatively limited experience, I've seen practitioners be rather deferential to other practitioners' ideas, (i.e., the test would get run because another practitioner wanted it, even if it wouldn't have been something the clinician would have done himself or herself) rather than the opposite. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 9, 2012 Administrator Share Posted March 9, 2012 In my relatively limited experience, I've seen practitioners be rather deferential to other practitioners' ideas, (i.e., the test would get run because another practitioner wanted it, even if it wouldn't have been something the clinician would have done himself or herself) rather than the opposite. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 9, 2012 Moderator Share Posted March 9, 2012 above all the trust between provider and the patient is huge if that is not there there is really nothing to do but go looking for it in another provider. Doesn't matter what your job is, what color you are or even what the condition is you gotta trust the person - -having said that your knowledge might well be hurting you or creating problems that are more yours then his. Think about it - were you just looking for zerba's? Ask questions at the office visit and see if he will educate you - then both win Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 9, 2012 Moderator Share Posted March 9, 2012 above all the trust between provider and the patient is huge if that is not there there is really nothing to do but go looking for it in another provider. Doesn't matter what your job is, what color you are or even what the condition is you gotta trust the person - -having said that your knowledge might well be hurting you or creating problems that are more yours then his. Think about it - were you just looking for zerba's? Ask questions at the office visit and see if he will educate you - then both win Link to comment Share on other sites More sharing options...
Acebecker Posted March 9, 2012 Author Share Posted March 9, 2012 I don't want to get into too much detail, but the case is a 2 year, 10 month old child with fevers ranging from 101 to 104 over the past three days. She's coughing, but there are no extra lung sounds, no TM redness - just a little sinus drainage and post-nasal drip. She can't tell me where she hurts or if she hurts. I have seen 90 cases of this in urgent care, so we did the standard parent stuff. Fever continues to spike. I sent my child with my wife to our doctor and my wife mentioned my concern over a possible UTI or some other explanation for high fever. He didn't run a UA or investigate the fever any further. Just gave her some Afrin. She's continued to have temps of 101. I don't feel like I'm asking about Zebras here. If I am, please let me know. If anyone says that this problem here is my knowledge getting in the way, then I'll gladly be quiet. Like I said, he's a family friend and I'd rather keep my kids going to him. Andrew Link to comment Share on other sites More sharing options...
Acebecker Posted March 9, 2012 Author Share Posted March 9, 2012 I don't want to get into too much detail, but the case is a 2 year, 10 month old child with fevers ranging from 101 to 104 over the past three days. She's coughing, but there are no extra lung sounds, no TM redness - just a little sinus drainage and post-nasal drip. She can't tell me where she hurts or if she hurts. I have seen 90 cases of this in urgent care, so we did the standard parent stuff. Fever continues to spike. I sent my child with my wife to our doctor and my wife mentioned my concern over a possible UTI or some other explanation for high fever. He didn't run a UA or investigate the fever any further. Just gave her some Afrin. She's continued to have temps of 101. I don't feel like I'm asking about Zebras here. If I am, please let me know. If anyone says that this problem here is my knowledge getting in the way, then I'll gladly be quiet. Like I said, he's a family friend and I'd rather keep my kids going to him. Andrew Link to comment Share on other sites More sharing options...
Guest raedd83 Posted March 9, 2012 Share Posted March 9, 2012 if the fever spikes for more than 5 days with no obvious source, specially in this age, start thinking about kawasaki disease or maybe roseola ( check for rash after the fever goes away) !! is there eye reddness? lips are red desquamation? check the CBC? is there any rash with fever? Is the kid up to date with vaccines? if the fever stays up to 4 days it still could be viral URI or it could be bacterial , after 5 days then either bactrial or something else. if the doctor didnt run UA , go to walmart and get the stuff its OTC, check UA and see if there is UTI ( is there any frequency, urgency, urine color, urine odor, gross blood). if you take the kid to the ER , ER doctors with this history will do lumbar puncture right away and sometimes its not needed, i hate it. check again is there any wheezing? crackles, congested chest? oh by the way, if im not mistaken , according to AAPA (pediatric association), cough medicine and decongestants are not prescribed to kids less than 6 years of age. new recommendations. best of luck :) Link to comment Share on other sites More sharing options...
Guest raedd83 Posted March 9, 2012 Share Posted March 9, 2012 if the fever spikes for more than 5 days with no obvious source, specially in this age, start thinking about kawasaki disease or maybe roseola ( check for rash after the fever goes away) !! is there eye reddness? lips are red desquamation? check the CBC? is there any rash with fever? Is the kid up to date with vaccines? if the fever stays up to 4 days it still could be viral URI or it could be bacterial , after 5 days then either bactrial or something else. if the doctor didnt run UA , go to walmart and get the stuff its OTC, check UA and see if there is UTI ( is there any frequency, urgency, urine color, urine odor, gross blood). if you take the kid to the ER , ER doctors with this history will do lumbar puncture right away and sometimes its not needed, i hate it. check again is there any wheezing? crackles, congested chest? oh by the way, if im not mistaken , according to AAPA (pediatric association), cough medicine and decongestants are not prescribed to kids less than 6 years of age. new recommendations. best of luck :) Link to comment Share on other sites More sharing options...
flyingsquirrel Posted March 9, 2012 Share Posted March 9, 2012 An LP would not be done empirically in a child of this age unless there were meningeal signs. The standard workup at my facility (Pediatric Level I) would include CBC, blood cultures, UA, urine culture, CXR. In a hypothetical situation, I would urge any parent with a legitimate, acute concern that is not appropriately addressed by the PCP (ie, persistent fever of unknown origin) to seek evaluation at a PEDIATRIC ED. Link to comment Share on other sites More sharing options...
flyingsquirrel Posted March 9, 2012 Share Posted March 9, 2012 An LP would not be done empirically in a child of this age unless there were meningeal signs. The standard workup at my facility (Pediatric Level I) would include CBC, blood cultures, UA, urine culture, CXR. In a hypothetical situation, I would urge any parent with a legitimate, acute concern that is not appropriately addressed by the PCP (ie, persistent fever of unknown origin) to seek evaluation at a PEDIATRIC ED. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 9, 2012 Moderator Share Posted March 9, 2012 it is VER Y traumatic to do the 'standard work up' is this a male or female? 2 1/2 years old is pretty much a competant immune system so would not get very excited - especially if eating and drinking and peeing and pooping okay - if the child looks non toxic then I would advocate for NOT doing anything.... (also UTD on shots?) male 2.5 yrs old with 4 days of fever that is acting well, drinking, wetting a lot of diapers...... gets maybe a little weight based APAP or Ibu NO COLD MEDS!! Under age 9 they are not indicated Doc might not be that far off - course it is a female with no shots and dry with a 104 you go to the ER - if female and non-toxic a hat collected urine would be reasonable Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 9, 2012 Moderator Share Posted March 9, 2012 it is VER Y traumatic to do the 'standard work up' is this a male or female? 2 1/2 years old is pretty much a competant immune system so would not get very excited - especially if eating and drinking and peeing and pooping okay - if the child looks non toxic then I would advocate for NOT doing anything.... (also UTD on shots?) male 2.5 yrs old with 4 days of fever that is acting well, drinking, wetting a lot of diapers...... gets maybe a little weight based APAP or Ibu NO COLD MEDS!! Under age 9 they are not indicated Doc might not be that far off - course it is a female with no shots and dry with a 104 you go to the ER - if female and non-toxic a hat collected urine would be reasonable Link to comment Share on other sites More sharing options...
Febrifuge Posted March 9, 2012 Share Posted March 9, 2012 When parents ask me for testing that's not needed, I explain why it's not needed, and also in what siutation it would be needed. Sounds like a bedside manner problem. But be aware, this doc might think he's being nice by not "schooling" you on why, from his point of view, you're asking for something a little crazy. Straight-cathing a toddler is not exactly an easy test for anyone concerned. Second the idea of a pediatric ER being the right place, if you need an ER. Link to comment Share on other sites More sharing options...
Febrifuge Posted March 9, 2012 Share Posted March 9, 2012 When parents ask me for testing that's not needed, I explain why it's not needed, and also in what siutation it would be needed. Sounds like a bedside manner problem. But be aware, this doc might think he's being nice by not "schooling" you on why, from his point of view, you're asking for something a little crazy. Straight-cathing a toddler is not exactly an easy test for anyone concerned. Second the idea of a pediatric ER being the right place, if you need an ER. Link to comment Share on other sites More sharing options...
Acebecker Posted March 10, 2012 Author Share Posted March 10, 2012 I didn't say anything about a straight cath - wouldn't consider this unless it was a dire presentation (dry kid who is truly listless). Leaving a sample via peri-bag is acceptable to make a Dx of UTI (not ideal, but acceptable). That is what I had in mind. UA is included in my standard w/u for a child this age (esp the girls) with fever without other definable cause. I expect this of other providers, too, I guess. And on other occasions this provider has done just that - gotten a UA for one of my daughters who had fever without other definite source. On this occasion he wouldn't hear of it. I found that less than thorough and contradictory to thorough Sx investigation. But some folks are more comfortble with the <3yo age group. How 'bout this: would you all have your children/family treated by other members of your medical group? Andrew Link to comment Share on other sites More sharing options...
Acebecker Posted March 10, 2012 Author Share Posted March 10, 2012 I didn't say anything about a straight cath - wouldn't consider this unless it was a dire presentation (dry kid who is truly listless). Leaving a sample via peri-bag is acceptable to make a Dx of UTI (not ideal, but acceptable). That is what I had in mind. UA is included in my standard w/u for a child this age (esp the girls) with fever without other definable cause. I expect this of other providers, too, I guess. And on other occasions this provider has done just that - gotten a UA for one of my daughters who had fever without other definite source. On this occasion he wouldn't hear of it. I found that less than thorough and contradictory to thorough Sx investigation. But some folks are more comfortble with the <3yo age group. How 'bout this: would you all have your children/family treated by other members of your medical group? Andrew Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 10, 2012 Moderator Share Posted March 10, 2012 How 'bout this: would you all have your children/family treated by other members of your medical group? Andrew I would not refer any of my friends of family to 7 out of the 12 doc's I work with - they are just far to concerned with the billable visit then actually giving care - but I do like a few of them.... Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 10, 2012 Moderator Share Posted March 10, 2012 How 'bout this: would you all have your children/family treated by other members of your medical group? Andrew I would not refer any of my friends of family to 7 out of the 12 doc's I work with - they are just far to concerned with the billable visit then actually giving care - but I do like a few of them.... Link to comment Share on other sites More sharing options...
Acebecker Posted March 10, 2012 Author Share Posted March 10, 2012 So picking a good one out of the group that you work with would be ok? No risk of conflict of interest? Link to comment Share on other sites More sharing options...
Acebecker Posted March 10, 2012 Author Share Posted March 10, 2012 So picking a good one out of the group that you work with would be ok? No risk of conflict of interest? Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted March 10, 2012 Moderator Share Posted March 10, 2012 How 'bout this: would you all have your children/family treated by other members of your medical group? Andrew Definitely....but this is more because everyone is salary-based, the hospital is nonprofit and everyone practices EBM as opposed to doing procedures/tests to increase the billing level. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted March 10, 2012 Moderator Share Posted March 10, 2012 How 'bout this: would you all have your children/family treated by other members of your medical group? Andrew Definitely....but this is more because everyone is salary-based, the hospital is nonprofit and everyone practices EBM as opposed to doing procedures/tests to increase the billing level. Link to comment Share on other sites More sharing options...
DizzyJ Posted March 12, 2012 Share Posted March 12, 2012 I didn't say anything about a straight cath - wouldn't consider this unless it was a dire presentation (dry kid who is truly listless). Leaving a sample via peri-bag is acceptable to make a Dx of UTI (not ideal, but acceptable). That is what I had in mind. UA is included in my standard w/u for a child this age (esp the girls) with fever without other definable cause. I expect this of other providers, too, I guess. And on other occasions this provider has done just that - gotten a UA for one of my daughters who had fever without other definite source. On this occasion he wouldn't hear of it. I found that less than thorough and contradictory to thorough Sx investigation. But some folks are more comfortble with the <3yo age group. How 'bout this: would you all have your children/family treated by other members of your medical group? Andrew Just read this article a couple days ago. I read the child you're discussing is 2yr 10mo and this guideline is for UTI's 2-24 months, but I thought it could still relate to the post here. It states a urine collection bag has an 88% false positive culture result. Actually recommends urines be collected by cath or even suprapubic aspiration. http://www.spapconference.org/upload/Presentation%20Febrile%20UTI%202011%20Guidelines%202012%20CB.pdf Link to comment Share on other sites More sharing options...
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