Children Doctor

By Erica Heilman

If a pediatrician spends an entire visit on a physical exam without actually talking and listening to the parent, that's not a visit to the pediatrician, that's an emergency room."

That's the professional philosophy of Dr. Herschel Lessin longtime pediatrician and medical director of one of the country's largest pediatric groups. It's an attitude that wins big with parents, but in the today's healthcare world where high volume is the bottom line, it's also increasingly rare.

Even in the best of worlds, pediatricians only have an average of fifteen minutes to spend with patients and their parents. After twenty years in the business, Lessin can learn a lot about little Johnny-and little Johnny's mother-in fifteen minutes. And like anyone else, he has his picks and pans. Which parents make visits easy and productive? Which just get in the way? We found out how this doctor thinks, and got some great tips for parents as well.

What kind of parents get gold stars for good behavior at the doctor's office?
HERSCHEL LESSIN, MD: Parents who ask questions and are not embarrassed to ask things that are of concern to them are serving the situation best. Just as important, parents who are willing to give the doctor's answers a fair hearing, even if those answers contradict what they may think they know, or what they've heard from family, friends or the Internet, are also on the right track. It's best if parents are willing to listen to what the doctor has to say and then come to an educated decision.

Do parents often come convinced of their child's diagnosis?
That just happened to me last week. I had a mom come in with three kids, that she said had pneumonia. She then told me that I was going to get them chest X-rays and do blood tests and I was going to prescribe them antibiotics.

And what did you do?
I spent about 45 minutes -- keeping my other patients waiting -- trying to explain to her why the children should not be exposed to excess radiation, did not need unnecessary antibiotics and did not have pneumonia. She wasn't hearing any of it. Those are the parents who get in the way of good medicine.

I don't dictate to parents, and parents should not dictate to me. My job, as I view it, is to convince you why my advice is better than your mother's. Ultimately, it's your child. But it's an interaction, a relationship.

Are some parents demanding antibiotics where perhaps they are not called for?
Yes, It's a big problem. It's enormously better than it was three years ago, when the media started publicizing the dangers of using antibiotics indiscriminately.

Why is it such a big problem?
For doctors in these days of managed care, where everybody is so busy and time is limited, it's much easier to just write the prescription rather than spend 15 minutes explaining why antibiotics aren't necessary.

It's essential to take that time to explain, and as a medical director, I work hard to get our pediatricians to follow the latest guidelines, and limit the use of antibiotics.

Okay, once you actually start the child's exam, what's the most useful thing a parent can do to help?
I think that a parent's willingness to understand that the kids don't want to be there is important, and that I may have to do things to them that they don't like. It's helpful if a mom tries to keep them calm and tries to make them comfortable, but also does what's necessary to help me complete the exam.

What do you mean by, 'do what's necessary'?
Well, there's a particular kind of parent that I struggle with...the kind who speaks to their two-year-old like he has a Master's in philosophy. I have to look in their ears and the mom is explaining to this two-year-old why it would be to their benefit for me to look in their ears. The two-year-old -- as two-year-olds are wont to do -- could care less what the mother wants or why, and finally I have to say, "We've got to hold this child down, because I have to look in her ear." But the parent will not restrain the child, and finally I have to call in a nurse, or hold the child down myself.

This seems a little extreme. Does this happen very often?
I don't have to use physical restraint often, but in those occasional moments, you need the parent to help you. The parent's job is to be a parent. And sometimes when you're a parent, you're not your child's friend. You're his parent. A parent can still be of comfort to their child while realizing that I have to do my job and examine their understandably uncooperative child.

When is it the parent's job to leave the exam room?
Well, I think it's really only in the case of adolescents. I like to examine teenagers alone, because when I talk to a teenager, it's confidential. The teenager is the patient, not the parent. I will encourage the teen to talk to their parents, but I will not break their confidentiality. It's the only way that they are likely to talk to me. I will explain this to the parents before they are asked to leave the exam room.

Check-ups are usually very rushed. How do you make sure there's time for parents' questions?
A good check-up is primarily for talking. I can do a full physical exam on a child in about a minute. That's really all you need to do a good exam, if you're well-trained and experienced. In the fifteen minutes allotted, a good check-up should leave about twelve minutes to talk to the parent.

What do you talk about?
Talking to the parent includes all of the anticipatory guidance. Safety, car seats, seatbelts, discipline, sleeping, eating. The list is endless. If you don't discuss those things, you're not doing your job as a pediatrician.

What should parents demand from their child's doctor?
Parents have a right to feel like their questions have been answered and their concerns have been heard.

Parents don't necessarily have a right to get the answers they want, but they do have a right to be heard, and have a reasonable discussion about whatever is concerning them.

If there is a complex problem a parent wants to discuss, there may not be time to discuss it at the check-up, and the parent should schedule a consultation of about forty-five minutes to come back and talk about it at length.

How often during these checkups do parents look to you for parenting advice?
All the time. With young infants, parenting advice is clearly the primary focus of the check-up. With older kids, it's generally only the focus if there's a serious behavior issue or school issue.

I could spend an hour and a half talking to parents about one single issue, like sleep habits. I usually don't have an hour and a half. So I'll often give them a five-minute synopsis and suggest a really good book to look at, or ask them to come back for a longer appointment concerning the issue at hand.

Do you find that these counsel sessions stray out of your field of expertise?
I'm not uncomfortable giving parenting advice unless I think there is behavior pointing to another diagnosis or something that I'm not equipped to handle. I'm a generalist, not a psychiatrist. I'm giving limited advice within time constraints.

But yes, sometimes you get kids that are really having behavioral issues that point to an actual mental health diagnosis. The problem is, mental health care for children in this country is woefully inadequate. In all but big-city areas, it is very hard to get a child psychiatrist, period. It is very difficult for these kids who need ongoing counseling and can't get it. Pediatricians are not trained to do it, and don't have time to do it. But sometimes they do it anyway because no one else will. You try to help people as best you can. Sometimes you're in over your head, but it's either in over your head or they got nothing.

As a pediatrician, you probably get asked about spanking a lot. Where do you stand on spanking?
The American Academy of Pediatrics has a position on spanking, and their position is you shouldn't spank children.

But to my mind, there's a difference between a spank and a spanking. As far as I'm concerned, the first spank is for the child, all the rest are for you. I have no problem with giving a kid a spank as an "I mean business" spank. Not to cause harm but to say, "This is serious." And if it's used judiciously -- not for every little infraction -- I think it's very effective. After that first one, the kid knows you mean business. Starting to hit him more just says you're out of control.

And finally, what are the rewards of working with children?
Hey, kids are fun. It's not like adults. I mean, you get to play and you get to wear goofy ties and you get to juggle. You get to do stuff that you can't do when you're in a white coat seeing an adult. So there are certainly rewards.

Copyright HLTHO - Healthology
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