Letters

Another heretic

I could not agree more with Dr. William G. Wilkoff’s Letters From Maine column entitled "Heresy" (November 2013, p. 14) that suggests that pediatricians should drop doing well-child exams on healthy school-age children! Having been at this for about 30 years, I can well remember not seeing older kids for 3 or 4 years at a stretch. There were a number of reasons for this: 1) They were perfectly healthy; 2) The parents had to pay for the visit (i.e., there was some disincentive to unnecessary utilization of medical services); 3) Schools did not require a form for every sneeze, fever, or sports activity; 4) The insurance companies were not telling us how to practice medicine.

What I don’t remember is any major medical problems that I discovered on these episodic well visits.

Currently, our office is engaged in a major campaign to bring in every adolescent who is "behind" in his or her yearly physical, because we are not meeting the insurance companies’ "quality metrics" and are thus missing uncaptured revenue. It seems as if every time I have a break in my 10-minute per sick patient schedule, I am asked if I can "squeeze in" another physical.

Worse yet, we have just added 1-month and 2-1/2 year physicals (after deciding many years back that they really were unnecessary), again for the same reasons!

Alas, I must ask you not to use my name, as my employer does not like squeaky wheels, but I do feel much better after whining to someone other than my wife. (Just don’t ask me how I feel about the indignities I just endured taking my recertification exam at a secured and proctored testing center.)

Anyway, thanks for articulating so many issues that are relevant to we "real" pediatricians.

Anonymous

I disagree

With all due respect for Dr. Wilkoff’s emeritus status, I politely disagree that pediatricians should not do routine physical exams on healthy older children. Gestalt: An integrated entity where the sum is greater than the added individual parts. That is what regular annual physical exams for older children represent to me. After 29-plus years of pediatric practice, it is hard for me to believe that school-based health care alone can uniformly provide equivalent evaluations on older children and teens. Yes, they can do hypertension and body mass index screenings. Yes, school nurses are an integral part of pediatric care, identifying children who need further evaluations and treatments, but they have distinctive educational and experience-based limitations. We diminish our profession when we degrade the importance of the annual pediatric exam.

So you may ask me, what more can the pediatrician provide? How about:

• Providing age-based anticipatory guidance.

• Providing the most up-to-date immunization information and discussions in our immunization-adverse society.

• Clarifying for families the frequent misinformation presented by television, the Internet, and social media.

• Assessing teen, social, and behavioral issues for children and families. (Example: More than 50% of initial attention-deficit/hyperactivity disorder inquiries in my practice come at a routine well-child visit.)

• Assessing risk factors and counseling for cardiovascular and other adult diseases.

• Assessing psychological issues for at-risk children.

• Providing continuity of care and identifying family issues.

• Assisting families by accessing comprehensive community resources when needed.

• Providing transition counseling for older teens as they enter college or the workforce.

Of course, all of this cannot be done at one well visit, but over the course of multiple annual exams, pediatricians can provide superior continuity of care. Perhaps I am a glutton for punishment. While some may groan as the summer approaches, I look forward to physical exams and touching base with my older patients. Fully 40%-50% of older children or teens with no identifiable issues at initial intake for a physical exam will have additional diagnoses at checkout. This occurs based only on simple questions and conversations during the exam. This is the gestalt of good pediatric care. So no, Dr. Wilkoff, your suggestion is not heresy, it is just not smart!

Ivri K. Messinger, D.O.

San Marcos, Tex.

Count me in

Count me a fellow heretic! I completely agree that my healthy school-age patients would thrive just as well without their annual well-child visits with me! Of course, we all enjoy maintaining the relationship with our families, and the visits are well reimbursed, but is there really any medical benefit?

I think not.

Vaccines and appropriate screening could be performed by registered nurses, freeing up slots for the pediatricians to see kids currently running to the urgent care centers.