A Pediatrician’s Dirty Little Secrets - Part 1
Robert P. Lindeman, MD, PhD
Natick Pediatrics, PC

In conversation with parents in my office, I often tell stories that reveal what I refer to as ‘dirty little secrets’ about pediatrics in today’s world. The title is a joke, of course: there is neither anything dirty nor secret about the stories. I refer to them as secrets because if these stories circulated widely throughout the community and if enough parents believed the stories to be true, primary care pediatrics as we know it would vanish quickly. Most pediatricians don’t want to vanish quickly. I know I don’t. That’s why these stories remain secret, until now that is.

The disappearance of primary care pediatrics would not necessarily be a bad thing. Children in the United States are arguably the healthiest human beings who have ever lived. The healthier the kids get, the less there is for a primary care pediatrician to do. Fewer problems for doctors to take care of: that’s a very good thing indeed!

In this series, I will publish some of the dirty little secrets of pediatrics that I’ve been telling privately over the years. I suspect that it will be a number of years before the general public begins to realize that these stories are true. At least I hope it will take years: I have a couple of college educations to pay for! (Just kidding…sort of.)

Part I – Most Visits to the Pediatrician are Unnecessary

Parents spend a lot of time in the pediatrician’s office. Before a child’s first birthday, there are no fewer than six scheduled well-child visits. There are three scheduled visits before the second birthday.

Then there are the "sick visits". Sick visits are almost always scheduled on the day of the visit, usually because the child has some symptom or condition that worries a parent. On a typical pediatrician’s daily schedule, there are more sick visits than well visits. The most common reason for sick visits is fever, followed by coughing/wheezing and other symptoms related to the lungs. Throw in some sore throats and painful ears and you have described 90% of a pediatrician’s day.

Now for the dirty little secret: Virtually none of these problems require a visit to the doctor. Fevers, colds, sore throats, sore ears, and even goopy eyes get better with home remedies that any experience parent can master. Time, comfort medicines, chicken soup and TLC are more than adequate for most of what ails our children. When the child gets worse or doesn’t get better despite excellent care from Dr. Mom, then the doctor may step in. But if all parents treated their children this way, pediatrics offices would be very quiet.

But pediatrics offices are never quiet. Pediatric waiting rooms and exam rooms are typically jammed with wall-to-wall children fairly bouncing off one another and the walls. Why is this so if American children are so healthy and most sick visits don’t need to occur?

There are several reasons:

First, it costs a lot of money to run a practice and pediatrics pays very poorly. In order to pay salaries, rent, and other overhead costs, pediatricians need to fall back on that time-honored business strategy known as volume. In order to stay out of red ink, a pediatric office needs to see lots and lots of patients, including many that don’t really need to see the doctor.

The second reason for packed pediatricians’ offices has to do with parents and childcare providers. Today, when both parents work out of the home, or single parents need to work, the illness of a child presents a cause for more than typical parental concern. Layered on top of worry about the child is the parent’s fear of losing her job if she takes too many sick days. Mom needs her baby to be well so she can stay at work. And it is seen as the doctor’s job to make the child well so mom can go back.

As long as a child remains in a day care setting surrounded by other small children, he is going to get sick often. Unfortunately, your average pediatrician cannot wave a magic wand and make the viruses go away. Many parents understand this, but unfortunately, many don’t. In addition, many childcare providers insist that parents bring their child to the doctor before returning to day care. Still more childcare providers insist that parents pick up sick children at the day care center and bring them directly to the doctor. Visits generated by childcare providers comprise a significant portion of my monthly revenue.

Finally, there is the 800-pound gorilla known as malpractice. We all know the gorilla is sitting in the corner but we do not wish to acknowledge he is there, lest we disturb his rest. Fear of malpractice, or defensive medicine, provides significant amounts of work for physicians in general, and pediatricians are no exceptions. We often ask worried parents to bring in their children because we are afraid that if we don’t, and there is a "bad outcome", that we will be sued.

That sad irony is that pediatricians are most often sued for "failure to diagnose" illnesses, the overwhelming majority of which are seen in office, complete with office notes that can later be obtained by a plaintiff’s attorney in a malpractice case.

What will happen if folks find out that most visits to the pediatrician are unnecessary? The laws of economics suggest that when there is less demand for pediatricians, the supply of pediatricians will have to shrink – in other words, there will be fewer pediatricians. Most well-child care will fall to general practitioners (who cared for most children until the 20th century), or to nurse practitioners and physician assistants, most of whom are already doing a terrific job at delivering pediatric primary care. And pediatricians will retreat to the great medical centers from whence we came. There we will provide care to patients who truly need pediatricians, critically and chronically ill children.

Dr. Lindeman enjoys practicing primary care pediatrics in Natick (Really!)