As every general pediatrician, family practitioner and nurse practitioner knows, the pediatric well visit is a rich, full 15-20 minute encounter. It is during this time that we hope to address all aspects of a child’s health and well being, with the ultimate goal of being able to “launch” that child into adulthood as physically, cognitively and emotionally healthy as possible. A few years ago, I realized I wasn’t just taking care of the child in front of me; I was also trying to care for the 25-year-old adult that child will become. No small task!
Luckily, we are not in it alone. First of all, we have our patients’ families. We know our patients and their parents, and have ongoing, long-term relationships. Don’t underestimate the strength of these relationships. Getting to know children and parents over time offers unique insights into how each child is being raised, which in turn lets us enter into care in a very respectful way. The power of these long- term relationships makes our profession so rewarding and allows us to provide high-level care.
Second, we have our training and resources to supplement it. We are trained to be on the lookout for hard-to-recognize potential problems in addition to addressing the more obvious medical problems at hand. And in this day and age, the ability to delve into the finer points of diagnostic dilemmas is easier than it’s ever been (can anyone say UpToDate?). Having access to an immediate, trusted, easy-to-use online pediatric medical resource is invaluable in keeping up with the pediatric field.
Third, we have the backing of many thoughtful organizations that provide age-appropriate topics and goals to address at each visit. The American Academy of Pediatrics (AAP) and Bright Futures are constantly refining their best practices for delivering pediatric care for each age group.
Even with all these resources at hand, conducting a useful well visit takes planning and preparation. I do not purport to have perfected the pediatric well visit, but in recent years I have made three worthwhile changes to my approach that seem to make the visit more useful for everyone involved
My well visits all begin the Sunday night before my week starts with a review of each upcoming child’s electronic medical record (EMR). I have found that if I quickly look at each patient’s chart in advance, in the quiet of my home, away from distractions of work, I can ensure that I am ready for the checkup. Most patients don’t need much of a “review,” but it is very helpful to see what I thought at last year’s checkup, check any recent specialist notes and make sure I have access to any labs.
I then pre-fill a visit note with reminders like, “last year was having recurrent ankle sprains and trouble with reading.” This brief reminder allows me to dive right into the things that will likely be on the parents’ agenda. And if last year’s problems have resolved, we can move on quickly to any new concerns.
When a patient arrives at our office, we have her or her parents complete a standardized, age-appropriate form. The questions cover all the usual age-related pediatric topics that either the AAP or Bright Futures would recommend. Getting all this information in one place before the patient walks into the exam room ensures that we address the myriad safety, nutrition, sleep, behavioral, developmental, etc., issues that I want to cover at each visit.
Over the years, my practice has updated these questionnaires to reflect current general pediatric concerns (e.g., questions about screen time use). In addition, our EMR system includes pre-made templates that highlight common issues and provide reminders about age-appropriate vaccines and screening tests.
Sometimes, the visit conversation takes a turn and reveals a significant concern. This can happen either because the parent wants to address something new at the checkup, or because I identify a medical issue that will take more time to elucidate.
I have learned (the hard way) that in those situations, I can’t do everything in one visit, and have become comfortable saying, “This is really important, and I want to make sure we have time to take care of this. Let’s finish the checkup, and then I’d like you to make an appointment to come back just for this newer problem.” By saying it this way, I try to convey that I need time to do my best job, and that something so important is worth setting aside more time. I am sure there are times when a parent wishes we could wrap it all up in one visit, but sometimes that is just not possible.
Someone once calculated that if we actually addressed all the mandated pediatric topics, each checkup would take 2 hours! But in reality we can do a lot in the typical 15-20 minute time slot. It’s not ideal, but it is the reality of medicine these days. Thus, it is to everyone’s advantage to be a fully prepared clinician when you walk into the exam room.
Susan Laster, MD, is a primary care provider in private practice in Brookline, Mass., and a member of the Pediatric Physicians Organization at Boston Children’s Hospital (PPOC).