From The 3 a.m. Handbook edited by William Feldman, M.D.
Handbook Published by Facts on File, Inc.; 0-8160-3802-3; $17.95US; June 98 Copyright © 1998 The Hospital for Sick Children
Choosing Your Child's Doctor
When young doctors are about to go into practice, they often ask older physicians what they need to do to be successful. For many years the standard answer has been: "Demonstrate the three A's." They are, in order of importance, ability, availability, and affability. When you're choosing a doctor for your child, these are three essential qualities to keep in mind.
What exactly do you mean by "ability"?
In Webster's New World Dictionary, "ability" is defined as "power to do [something]; talent; skill." The powers, talents, and skills your child's doctor should have can be categorized into four broad areas: prevention, diagnosis, treatment, and rehabilitation.
In the field of prevention, your child's doctor should be aware of which preventive measures work and which don't. For example, certain screening tests for newborns are very effective in preventing mental or physical disability, and should be performed on all newborns. "Well-baby visits"--routine medical checkups when nothing seems to be wrong--provide immunization and advice that can prevent life-threatening problems later on.
Diagnosis means discovering the root of a problem such as fever, pain, difficult breathing, or disturbing behavior. The physician should be skilled at reaching a diagnosis by various means. The first and most important is simply asking the parents (and children, if they are not too young) for a description of the problem: whether it's getting better or worse, what makes it better or worse, how it's affecting the child's (and family's) life. The answers often go a long way toward identifying the cause of the problem. The second means of diagnosis is the physical examination. The third is laboratory tests. In general, the more experienced physicians are in diagnosing and treating the medical problems of children, the less they depend on lab tests. There are, of course, problems that require certain tests or X rays, but the most able diagnosticians rely heavily on asking questions and on physical exams.
The fourth means of diagnosis is referring the child to another doctor for consultation. Some doctors are so busy seeing large numbers of patients that they don't have time to ask the extra questions or to do the detailed physical examination needed for a diagnosis; they tend to refer too many children to consultants. Other doctors are overly confident of their own abilities, and they may not refer enough children to consultants.
Modern treatment has changed dramatically in the last hundred years. In the old days doctors didn't have a lot of effective medications or surgical procedures to offer, so they were much better at diagnosis than at treatment. In the last century, however, we have developed a host of effective treatments, as well as more sophisticated diagnostic tools. However, just as the treatments have become more powerful, so have some of the side-effects become more serious. Therefore, the most able physicians are those who use treatments that have been shown to do more good than harm. Fortunately, modern physicians--and increasingly aware consumers--are asking for proof that a treatment is necessary, and that the outcome is likely to be better than it would have been with no treatment.
Rebabilitation is the fourth critical area of skill. Some problems, like asthma or cerebral palsy, are "chronic" and can't be cured--we just have to live with them. An able doctor tries to rehabilitate a child with a chronic problem, to enable the child to live with as few limitations as possible. In the case of asthma, medication given when the child is well will usually prevent attacks and allow the child to attend school and play sports. In the case of cerebral palsy, the doctor should know which medical and non-medical consultants can help the child lead as full a life as he or she can.
How much "availability" should I expect from a doctor?
Children get sick, and parents have anxieties, at all times of the day and night. Most often the experienced parent knows when a problem is a real emergency and the child needs to be seen by a doctor without delay. But parents need time to acquire experience, and they need sources of information. We hope this book will help you determine when it's necessary to call your doctor at 2:00 A.M., or rush to an emergency room; we also hope to give you some advice on what steps you yourself can take to make your child feel better while you're deciding whether to call the doctor.
Nevertheless, most parents, no matter how experienced and knowledgeable they are, will need to get in touch with their doctor sometime because their child has an acute problem. And that's when accessibility becomes crucial. Even during office hours, a very busy doctor may be hard to reach because the telephone is constantly in use. Many physicians get around this by having extra telephone lines, so parents can always get through.
Of course, the big problem with availability comes during nights, weekends, and holidays. We recently did a study of after-hours availability in four major Canadian cities. We made phone calls after office hours to doctors who look after children--family physicians and pediatricians--and took note of the messages left on their answering machines or voice mail. We classified a physician as available when the message said that the caller should leave a name and telephone number and that either this physician or the on-call (substitute) physician would reply shortly. When the message said that the office was closed and the patient should be taken to the nearest emergency room or walk-in clinic, we counted the physician as not available after hours.
We found quite a difference in the four cities. In one city, almost all the doctors were available; in another, about three-quarters were not available.
Physician availability gives parents a sense of security, and it's also important for other reasons. A telephone discussion between the parent and a physician solves the majority of after-hours problems; the physician gets enough information to decide whether the child needs to be seen at once, and in more than half the calls, the decision is that there is no need for a doctor to see the child. This not only saves money for the health-care system, but also spares the family a lot of trouble and lost time. Furthermore, each episode successfully handled with after-hours telephone consultation helps give parents the experience and knowledge they need to become less dependent on the health-care system.
No parent can expect a physician to be on call twenty-four hours a day, seven days a week. Years ago many physicians did practice this way, making housecalls, creating a special bond of caring between themselves and the families they served. Although they didn't have many effective treatments to offer, they demonstrated a helping mission that was in itself often therapeutic. Nowadays doctors have many effective treatments to offer, but until fairly recently medical schools concentrated on the curing, not the caring, aspects of being a doctor. That is now changing, as medical educators try to develop an appropriate balance of curing and caring in selecting and educating future doctors.
Most "available" doctors these days practise in on-call groups; this approach enables patients to obtain immediate advice, and doctors to have time for their personal lives. A physician who does not provide an afterhours on-call service, whose message is "Go to the emergency department," should not be your first choice.
Why does "affability" matter in a doctor?
Webster's defines "affable" as "easy to speak to; approachable." We define"affability" to mean the quality that makes you feel at ease talking with a physician--confident that you aren't being rushed out, that the doctor really is interested in discussing your concerns. This climate of interest should be apparent in all office staff--the receptionist, nurse, and others in the practice.
There are several ways the doctor and staff can demonstrate their interest and concern. One is the office setting itself. Although it need not be luxurious, it should at least be pleasant and comfortable, particularly the waiting area. There should be interesting, up-to-date reading material for readers of all ages, as well as toys and games for younger children. The most important components of affability, however, are the interpersonal skills of the doctor and staff, and the feeling that you are not being processed on an assembly line.
The interpersonal skills should include friendliness and the demonstration of a genuine affection for children. Also, the physician should use language the child understands. Often a child can help in arriving at a diagnosis. For example, if a nine-year-old has recurrent tummy aches, the doctor may ask the parent if there is any constipation--a common cause of abdominal pain. But the parent may have no idea of the child's bowel habits, and the child may not understand what "constipation" means. If the doctor asks the child, "Does your tush hurt when you poo?" and the answer is yes, the problem may be solved.
This easy communication should exist at all stages of the system. When you telephone for information or an appointment, you should be made to feel that your request is as important to the doctor and staff as it is to you. When you are seeing the doctor with your child, you should be made to feel that you can discuss anything you wish and that the doctor won't consider it frivolous. When a test is being ordered, you should feel free to ask why it's being done and how the results of the test will affect your child's treatment. You should never leave the office with questions you would have liked to ask. In fact, the affable doctor will usually ask if you have any unanswered questions, or anything else you would like to discuss, before you leave.
The best physicians combine ability with availability and affability. Although these are also the doctors with fairly large practices, they usually have excellent time-management skills, and the people in their care don't feel rushed.
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