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It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.
On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.
But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.
Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.
Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.
Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”
In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.
Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.
I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.
As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.
It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.
On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.
But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.
Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.
Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.
Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”
In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.
Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.
I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.
As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.
It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.
On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.
But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.
Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.
Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.
Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”
In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.
Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.
I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.
As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.