10 Things Your Pediatrician Won't Tell You

Pediatricians in California, for instance, are paid around $24.24 per month per patient by HMOs, even though the average cost of caring for a patient and administering all the mandatory immunizations is $47 per month, according to a study by the California Medical Association. The disparity between HMO reimbursements to pediatricians and to adult internists is considerable, adds Dr. Philippa Gordon, a pediatrician in Brooklyn, N.Y. She says the typical internist receives $200 from an HMO for a basic physical exam of an adult, while a pediatrician would receive as little as $100 for performing that same service on a child.

How might a doctor compensate for that financial disparity? Says Dr. Joel Bradley, a pediatrician based in Clarksville, Tenn., "When the financial pressures are heavy, all physicians feel pressured to spend less time with a given patient." Dr. Lawrence Diller, a Walnut Creek, Calif., behavioral pediatrician — and the author of Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill — says that pediatricians who do spend a lot of time with their young patients are typically a practice's "loss leaders." He adds, "Pediatricians lose money by spending a lot of time speaking with patients. There are great economic disincentives to doing an adequate examination."

2. "My assistant does most of my work."
Most people today take their kids to the doctor and deal with everyone, it seems, but the doctor. Someone else takes your child into the examining room, asks all the questions, gives the shots and takes the vital signs. What you are experiencing is the physician-assistant phenomenon, which, in an age of medical efficiency, is booming. Physician assistants typically complete a two-year medical program, learn many of the clinical skills that are used in primary care and are an asset to many offices. Pediatricians argue that the use of assistants allows them to more efficiently use their skills and time.

This may be true, but how qualified are these assistants to actually treat a young patient's maladies? Philippa Gordon — who does not employ physician assistants — points out that they can be fine, as long as they're not getting in over their head. "You need to have clear guidelines as to when the pediatrician needs to be called in," says Gordon, ticking off abdominal pain, joint problems and newborns with fevers as examples of things you would want the physician to handle. "Limits need to be set."

3. "I make diagnoses just by looking."
When Pat and Sue Sheridan's first child was born in 1995, doctors did not think much of his jaundice. Neither did the Sheridans — until the baby, just four days old, wouldn't wake up. When Sue called the hospital, the nurse there suggested that she visit her pediatrician, who prescribed antibiotics for an ear infection and sent them on their way. When the baby seemed worse the next day, Sue took him to the hospital, where his blood was tested for the first time. "Nurses there told us it was the [worst case of jaundice] they had ever heard of," she says, adding that her son's blood should have been tested at birth to detect the extremity of the jaundice. "Now he's five years old, he can't walk and his speech is impaired." (In 1999, a jury found the doctor and hospital not liable for any of the charges. A judge, however, granted a retrial — which is now being contested by the defense — saying that he was "dumbfounded" by the original verdict, which he found totally inconsistent with the evidence.)

Like the Sheridans' doctor, pediatricians often use their eyes to make diagnoses. This is helpful when it is combined with a thorough physical examination. When it's not, it's irresponsible. Dr. Barbara Korsch, author of The Intelligent Patient's Guide to the Doctor-Patient Relationship and a professor at Childrens Hospital Los Angeles, knows it happens too often. Recalling instances in which she's examined children in front of their parents, Korsch recounts, "I've had patients' mothers say to me, 'My goodness. Our pediatrician did not give my child an examination.' You can learn a lot from observing a child, but that in itself is not enough. When it's all you do, it's dangerous."

4. "My waiting room is a breeding ground for disease."
Chuck Gerba, a professor of microbiology at the University of Arizona, is a germ hunter. One of his studies entailed finding the places where germ-filled bodily fluids were most likely to show up. Second only to restrooms were the waiting rooms of pediatricians' offices. "It makes sense when you think about why all the kids are there," he notes.

How do you make sure that your kid doesn't leave the doctor more germ-infested than when he came? Gerba offers three strategies: Tell your kids to keep their hands in their pockets. (Yeah, right.) Be sure that they stay away from the toys (which every other kid has put right into his mouth), and bring along hand wipes. Some pediatricians have found their own solutions, like seeing healthy kids in the mornings and setting aside the afternoons for sick kids. That said, Gerba is not surprised that many pediatricians' waiting rooms are rife with germs. "Pediatricians are not versed in public health and sanitation," he says. "That's why you should always wash your hands when you leave the pediatrician's office."

5. "ADHD is my favorite disease."
Dr. Lawrence Diller estimates that as of 1998, 3.75 million kids in the U.S. were being treated for attention-deficit/ hyperactivity disorder. The diagnosis is usually arrived at quickly: A parent will come in with a kid who is fidgety in class, misbehaving at home and unable to focus for very long, and the pediatrician will declare that the child has ADHD. Dr. Mary Ann Block, a pediatrician in Dallas and the author of No More Ritalin, thinks that the glut of ADHD diagnoses is a by-product of physicians' looking for quick and easy answers without searching for the root cause of the symptoms: "Laziness [on the part of the pediatricians] is one part of it," she says.

Another part is surely the doctors' financial pressures, says Lawrence Diller: "The American Academy of Pediatrics came out with guidelines for evaluating ADHD. But doctors who are willing to do it will go broke. It entailed meeting parents, speaking with a teacher, spending time talking with the child to rule out other emotional and behavioral problems. Nobody will do that on a regular basis."