February 16, 2010

The Knowledgeable and Empowered Parent

raphaellas help note 1-16-10 Last night I went over to the home of a couple of my patients to drop something off.  The dad greeted me at the door and said that his daughter had something for me.  The 7-year-old gave me the picture above.  Impressed as I was, I asked her why she chose this subject.  “Because we were really sick!  You could have made us feel better.”  But I didn’t know anything about it.  Her parents had never called.

Much of what I write about could be called parenting.  Hopefully, the cases I describe are instructive in some way.  It’s logical that a first-time parent will learn more new information than a more experienced parent, who have seen and experienced so much.

Indeed, part of my Slow Medicine practice model (described in parts 1, and 2) is taking the time not just to engage with the child but also the parents.  I want to make the parents feel like an essential part of the health apparatus applied to their child.  In what I call the ‘factory model’ of medical care currently being practiced, patients are nameless widgets whose crucial function is to be passively processed as quickly as possible.  Above all, they can’t be allowed to slow the velocity of throughput.  I want to take the time to explain things to parents, describe my approach to the problem and what the options are as I see them.

Over time, however, I have discovered an unexpected aspect of this method.  Empowered families feel empowered.  Strangely, this hadn’t occurred to me right away.  I did realize that from the payer’s point of view (the insurance company), it was an absurd and obvious false economy to push patients to be seen as quickly as possible.  Though it might cut insurance expenses this month or this quarter, over time each patient would have to come in again and again for their one or several problems.  Teaching them to manage their own care better will save both patient and insurer a lot of real money.  Keeping patients out of ERs would save even more.  This post, however, isn’t about the counterproductive financial incentives of our dysfunctional system, and the ways it doesn’t work.  This post is about the system I came up with, and how it does work.  I want to be up-front about the economics, however, and get that out of the way.  Like every primary-care physician, I am paid per visit.  No visit means no pay.  It may be true that if you give a man a fish you feed him for a day but if you teach him to fish you feed him for a lifetime.  Still, it seems strange to run a fish store with a tuition-free fishing academy.

(As an aside, when I was in Business School a few decades ago, piecework was considered so obsolete and ineffective a model of employee compensation that it wasn’t really covered.  I couldn’t have guessed that one day I’d be living the dream.)

In The Telephone Paradox, I note my experience of changing people’s behavior just by answering the phone.  Not so much but what I say, but just by picking up.  As parents came to believe that they really could reach me directly at any time, nights or holidays, they actually called less.  They came to see that since they could always call if the child got worse, they could wait and see for a moment.  Given the opportunity, many of those sick children did get better on their own, and so the parent never actually called the doctor.

My practice is populated by a very diverse group of families.  Many of the nurses at the nearby hospital bring their children to me, along with many of the physicians.  They all know lots of things that I don’t know.  As the parents in non-medical fields become more educated and empowered, by me and by their own experience, they too make a lot of their own treatment and diagnostic decisions.

‘This is what I wanted!’ I sometimes have to remind myself.  A group of smart, independent-thinking, empowered parents who can handle a lot of routine medical issues.

The problem is, they don’t come to the office.  When the children get sick, these parents are rightly self-assured that they can handle it.  They were carefully instructed by me about the method and purpose of treatment, and what to watch for.  Besides, they know they can call me at any time.  I’ll always see their child the same day, even if it’s at night or I have to come to their home.

As it turns out, I’m not sure this is really ideal.  I worry about parents being a little too confident, and missing some important aspect of the child’s condition.

I also worry more about missing patterns of illness that I might pick up over time, by seeing when or how often certain symptoms were happening.  In the case of Tammy, her horrible rash kept appearing on Mondays, a day after visiting grandma.  There are many medical problems that are identified by pattern-matching, and like a pixelated picture, more data produces a clearer image. 
Surprisingly often, I see a child in the office with the following dialog.
“It’s nice to see you.  How have things been going?”
“Great,” says the parent.  “She’s been really healthy.”
“I’m glad to hear it.  So what brings you in today?
“Well, she’s been coughing a lot at night.”
“For how many nights?”
“I don’t know exactly.  Maybe 4 or 5 months.”
There are important, unspoken—and mostly unstudied—aspects to medical care and the doctor-patient interaction.  Her parents may have been right in deciding that they knew how to handle the illness and I wouldn’t have changed anything.  But for children (and this is true for many people of all ages), going to the doctor helps to make them feel better.  I think it’s one of the reasons that people sometimes complain when the doctor never examined them or listened to their heart, even if they are there for an unrelated problem.  I think there’s a real therapeutic value in physical touch and just listening attentively to the patient’s complaint.  So although her parents may have been precisely right about the appropriate therapeutic intervention, and maybe I couldn’t have made the child get better sooner.  But they didn’t see that maybe I could have made her feel better sooner.

Perhaps this is why doctors and nurses bring their kids to me.  I may not know more, but I’m the doctor, and that gives them permission to be mom and dad.

1 comment:

  1. Interesting topic.

    Love the illustration. Hilarious!



Please let me know what you think. Do you know a child or situation like this?