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"Practical approaches to common gastrointestinal symptoms" (April) includes some important, well-made points. The identification and discussion of types of doctor-patient relationships are valuable, as is the discussion of components of illness that need to be considered and addressed. Knowing, understanding, and using such a structure can be quite helpful to the practicing pediatrician.
Nonetheless, the black-and-white portrayal of the "biomedical model" contrasting with the "biopsychosocial model" angered and annoyed me. I think this presentation confines, misstates, denigrates, and belittles the true biomedical model. I cannot imagine any clinician blatantly ignoring the psychosocial aspects of the patient and family. Likewise, the biopsychosocial approach, as the article describes it, tends to deny both the reality of the physical pathology and the strong interrelationship between mind and body, as shown by many studies.
Secondly, from the standpoint of the practicing pediatrician, the author's charge to focus on the psychosocial aspects of patients' problems in the manner he describes is unrealistic and therefore unconvincing, given that this approach requires a time commitment of from two to more than three hours. A pediatric clinician cannot even consider attempting this approach without strong direction and advice about how to organize and find this kind of time in this era of managed care. Given HMO contractual requirements and the lack of reimbursement for long visit codes, the maximum reimbursable time for a pediatrician is 40 minutes. Unless the author can describe a way to handle the GI problems he describes in 40-minute units, his approach is impractical for a practicing pediatric clinician.
Christopher W. Goff, MDOld Saybrook, CT
Dr. Fleisher's review is refreshing in a day and age when we tend to save time by relying on technology. At first glance, his suggestion to spend "two to three and one-half hours" with a single patient seems impossible, given our current reimbursement climate. I have developed approaches similar to those suggested by Dr. Fleisher for the three problems he delineates without going bankrupt, however. I suggest keeping the following ideas in mind:
Since the situations Dr. Fleisher describes are not emergencies, multiple office visits can be used to reach the same goals he achieves in a single prolonged visit. I find that in addition to increasing reimbursement, multiple visits permit parents and patients to "digest" the concepts I have presented and accept the treatment plan.
As primary care practitioners, we general pediatricians have an advantage over the specialist. We often have an ongoing relationship with the patient and parent before the GI problem arises. We also may have a sixth sense about where the patient is coming from and where he is going. This gives us a head start in arriving at a diagnosis and treatment plan.
An unhurried approach to a parent and patient by a sympathetic health-care provider is actually the beginning of a treatment plan. We must always be compassionate, sensitive, and caring, even when time is limited. This does much to reduce anxiety.
Thank you, Dr. Fleisher, for your insights.
Charles H. Staab III, MDWheeling, WV
The author replies: I quite agree with Dr. Staab that the illnesses of children who vomit and fail to thrive or who withhold bowel movement or complain of abdominal pain and stay home from school aren't necessarily emergencies. I also concur that most children whose illnesses have significant psychosocial components can be managed by caring, sensitive, intuitive primary care physicians over the course of several regular office visits.
By contrast, the illnesses of the three children in my article had become quite emergent. Despite many office visits to excellent pediatricians and subspecialists, each case had become a crisis with mounting iatrogenic morbidity. The referring physicians in cases 1 and 3 insisted that I see their patients without delay. The parents in case 2 traveled 1,700 miles for the consultation.
I'd like to discuss the concepts of "emergent" and "nonemergent" and relate them to the indications for unconventionally long consultative visits. Dr. Staab implies that organic diseases can be emergent but functional disorders cannot, because they don't cause structural damage. Even if I were to agree, this distinction is irrelevant because no one is able to know beforehand how much of a patient's complaint is due to organic or functional or other causes. The vomiting infant with failure to thrive could have had a Bochdalek hernia; the toddler with dyschezia could have had a rhabdomyosarcoma of the pelvis; and the girl with abdominal pain could have had a brain tumor. Any child with a functional disorder may also have organic disease plus any or all of the remaining four categories of factors contributing to their illness.
If parents perceive that their child may be having a health emergency, we respond as though there may indeed be an emergency. Once we determine that the child's symptoms aren't as serious as thought, we apply our communication skills to relieve the parent's fears. When the pediatrician deems the child's problem a nonemergency while the parents continue to believe that it is, referral to a subspecialist who schedules longer visits may help.
What does it take to change parents' perceptions? Doing whatever is necessary to allow both physician and parents to feel that they have a plausible diagnosis, an idea of how the illness came about, how serious or safe it is, what they can do about it, and a time frame for recovery. When these essential communications take hold, the fear subsides, the parents feel secure in their choice of doctor, and they are eager to implement the agreed-upon plan of treatment.
The amount of time needed to bring a perceived emergency under control is difficult to predict because its complexity reveals itself only during the course of evaluation and treatment. Whether a perceived emergency involves an unconscious child who's just fallen from a window or an inconsolable toddler who screams and runs frantically about whenever he feels the urge to defecate, once the clinician's work begins it must continue without interruption until everyone feels that the danger has passed. One cannot stop partway just for convenience.
Therefore, the use of long consultations for extremely complex perceived emergencies is just as valid as the use of more conventional office visits for nonemergent cases involving the same diseases or functional disorders. We must acknowledge the difference between nonemergencies and perceived emergencies and understand that difference as it affects the way parents and pediatricians behave toward each other.
Should general pediatricians and family practitioners attempt to deal with the kinds of complex illnesses exemplified by the case vignettes in my article? Those who feel competent to do so should, and they should charge for their time. Should third-party payers pay for treatment of patients with such complex problems? They certainly should and doone way or the other! When they pay attention to clinical realities and view health care as a service to patients with individual needs, they abet healing and save money.
The information about determining readability in "Making handouts easy to read" (April) is helpful. Our practice has discovered other ways to make it easy to distribute handouts and make them inviting. We keep handouts in a drawer in each of our exam rooms; this accessibility makes it easier for us to use the handouts frequently. The more papers a handout has, the more likely reading them will be regarded as a chore, so we try to keep handouts to one page. Printing on both sides of a single page is therefore preferable to using one side of a two-page handout.
Thank you for "Poison ivy update" (April). The pictures of the various offending plants are especially well done, and we plan to use them to educate our patients who experience this very uncomfortable acute dermatitis.
We do have some concerns about using corticosteroids for managing Toxicodendron dermatitis. We agree that oral steroids are often effective for managing moderate to severe cases. However, we have found that a short course (three to five days) of prednisone at 1 to 2 mg/kg/d is often associated with a recurrence or rebound of the dermatitis at the original sites of involvement. In these cases, continuing the treatment for two to three weeks with slow tapering of the steroids is effective.
The authors mention using injectable corticosteroids to manage severe cases of dermatitis. This calls for great care since the skin may atrophy at the injection site, particularly when the repository forms of injectable steroids are being used. In general, we believe that injectable steroids should be discouraged because they have no benefit over appropriate doses of oral steroids that are given promptly.
As a pediatric subspecialist, I rely on Contemporary Pediatrics to keep me well-informed and updated on issues faced by pediatricians in general practice. I particularly enjoy the Pediatric Puzzler, which gives me an opportunity to refresh my differential diagnosis skills and to approach the children in my practice with a wide-angle lens. I was therefore a bit disturbed by what I thought was a narrow approach to a very ill child in "Persistent fever in a 6-year-old: Licking the diagnosis" (April).
The child had multiple signs and symptoms that pointed to the need for a bone marrow aspiration and biopsy as part of her work-up. In addition to a history of prolonged fever, as well as lymphadenopathy and hepatomegaly on exam, she had abnormalities in two of her cell lines on her complete blood count. The authors do mention that malignancy is on the list of diagnoses to be considered and that a review of the peripheral smear is indicated. It is well known (and well reinforced in our teaching to medical students and residents), however, that children with new-onset leukemia may have normal smears in a significant percentage of cases. In addition, this child could easily have been manifesting tumor lysis syndrome, with an elevated lactate dehydrogenase, decreased urine output, and abnormal electrolytes. Her subsequent deterioration, resulting in an intensive care unit transfer with hemodynamic support, is most suggestive of infection. Performing a marrow aspiration while awaiting titers for Rocky Mountain spotted fever and Ehrlichia would probably have been in this patient's best interest.
Sarah Friebert, MDCleveland, OH
The author replies: We appreciate Dr. Friebert's concern regarding our child with human monocytic ehrlichiosis. The fever, lymphadenopathy, hepatosplenomegaly, and abnormalities in two cell lines are the clinical findings that caused us to include malignancy on the differential and review the smear. The child became ill early in her hospital course and was prepared to transfer to a tertiary institution where consultation with a pediatric hematologist was obtained. This consultation resulted in a bone marrow aspiration on the day of transfer. The findings were consistent with infection. There was an early myeloid predominance with erythroid hypoplasia, increased phagocytic macrophage activity with occasional large vacuoles, and relatively decreased numbers of neutrophils and lymphocytes. There were no phenotypically abnormal cells. We hope this information is helpful and agree that children with this clinical picture should have an evaluation by a pediatric hematologist/oncologist.
Brian Sard, MDBaltimore, MD
Julia McMillan. Letters. Contemporary Pediatrics 2000;8:16.