An approach to patients

Dr David F Smith Physicians, both men and women, can appear imposing or even frightening to some children. I’ve found that an initial discussion with the parents, preferably while seated and with the youngster playing with toys in the room, works best as a start. Acceptance of your presence by a child requires time. Once the examination is about to begin, I’ll have a parent hold a toddler on his or her lap to provide the child an initial sense of security. If the child is a bit older, I’ll often have the parent place the child in an upright seated position on the side of the examination table to avoid, initially, putting the child in a recumbent position. Children usually feel more in control in a sitting position and are less inclined to cry. I tend to avoid standing initially; I’ll move on an office chair with wheels over to the side of the examination table. This puts me on the same level as the child and is less threatening to the youngster than standing over him or her. I’ll start with an examination of the feet while the youngster dangles them over the side of the table. There’s a lot to be learned clinically from the feet. They are also the most distant body part from the head, which, in turn, is usually the area of greatest examination concern for the child. Once the foot examination is completed, you can remain seated and still examine the heart, listen to the chest, check the legs, arms and hands and then, finally, stand up to examine other areas. If there’s been no crying up to this stage, then the remainder of the examination usually goes smoothly. Don’t forget to check the scalp. Even in our best Vancouver (British Columbia) schools, lice checks usually result in a discovery rate of at least 1% to 2%. In addition, there may be the odd old head laceration, reflecting past injury, which will appear as a whitish scar in the scalp area. I once saw a 12-year-old youngster from the British Columbia interior for a failure to thrive assessment. His scalp examination revealed 30 old scalp lacerations, none of which were apparent on initial inspection. On questioning his mother, she reported him as being “clumsy”. I telephoned the child’s local hospital to obtain his emergency records, and discovered that no medical care had ever been provided for any of his full-thickness scalp lacerations. After his subsequent permanent removal (by provincial authorities) due to long-standing child abuse, his growth and mood improved significantly. The written record is a key component in the practice of medicine. I once served as a medical consultant in a legal case concerning a young child with meningitis who had a probable missed diagnosis. I say probable, because the main indicator of malpractice was an abbreviated and incomplete emergency medical record. No mention of neck stiffness was recorded in the emergency medical record, and this posed a big problem for the attending physician. As a general rule, it is assumed that if a doctor is ‘thinking’ about meningitis, then the neck status will be documented. The absence of such information in the record implies that it was not part of the physical examination. A physician later stating in court that the neck examination is always part of his or her practice is unlikely to be believed. The neck status became a focus in court and the medical notes were too abbreviated to be of assistance to the physician defendant. A physician’s defense will depend on the medical file, which is usually compiled when legalities are not in play. Memory for detail fades over time, so physicians may need to rely entirely on their medical records in cases of review or legal contest. As a result, the more complete the records appear, the better the outcome for a physician. Based on that case alone, I would recommend that every physician regularly examine his or her medical notes for completeness. If you had to defend them in court, would they stand up to scrutiny? So anticipate possible communication problems in difficult situations and provide extra dictation or record keeping…. just in case. I worked as a paediatrician on child abuse teams over a period of 25 years, appearing in court more than 100 times as a medical witness, usually on behalf of the Crown Counsel. While the focus of the court was usually on alleged child abuse, the effect on me was frequent disruption of my working day. Regularly, I would receive subpoenas to appear in court. I would cancel or postpone patient visits, arrange for teaching coverage and organize travel. Then late in the afternoon the day before, or sometimes the morning of the scheduled court appearance, I would be informed by telephone that the case had been settled and my services were no longer needed. Over time, I toughened my approach to legal demands. I would clarify payment obligations through discussion in advance, and I asked to be informed about how a particular case was progressing. I set an expectation of legal courtesy, and by that I mean lawyer courtesy, and I refused to accept last-minute subpoenas due to lack of Crown planning and preparation. Once in court, there is a legal expectation that a defense lawyer, when cross-examining at trial, will attempt to discredit either the testimony or the witness’s credibility. On one occasion, I ran into an aggressive lawyer who set out to discredit me. He was unpleasant and his manner was grating. Many judges will stop this approach, but this one did not. After an irritating cross-examination, during which he made snide remarks about the medical opinions expressed in the case, he then addressed the child’s growth. Stopping at this point, he turned to me and stated sarcastically, “You do know something about growth and development, don’t you?”. I said nothing. After a period, the lawyer asked me if I intended to reply. “No”, I stated. The lawyer addressed the judge and said, “He’s not replying”. The judge turned to me and asked, “Why aren’t you replying?”. “I found the question to be rude and offensive”, I stated calmly. The judge turned to the lawyer and asked him to rephrase his question. The lawyer expressed surprise at the request, but his tone and manner changed dramatically. The rest of the cross-examination was conducted quietly with no further aggravations. Stand up for yourself in court. As a physician witness, you are not there to be abused. When considering management as part of your occupational activities, ask yourself whether this is something you would like to do and something you think you may be good at. If the answers are positive, then there’s no reason to hold back. But as the Boy Scouts have consistently said, “Be Prepared”. I have a few brief suggestions. If you find your staff doctors are fighting, look for a money issue. Avoid discussing your subordinates when they are not present. Be dependable and reliable. Address manipulative behaviour directly when it occurs. Be direct. Recognize that parental complaints will inevitably take precedence over anything else that you do, and deal with these promptly. Do not get mad, at least openly, and avoid any tendency to ‘get even’ because this seldom proves beneficial. Identify positive features and strengths in your staff and encourage and develop these. One lesson, which I fortunately learned early on, is to consistently telephone the references of your job applicants. Some medical supervisors feel greater responsibility for those they trained than for their colleagues. Some write rave letters of review on a trainee’s behalf, which do not accurately reflect performance. Do not take reference letters strictly on face value. If there is an inconsistency in the pattern of the trainee’s program or the applicant has trained in many centres, consider the possibility that the reference letter(s) may reflect a desire to move the individual along. Good administrative decision making and departmental popularity do not necessarily go hand in hand. Nevertheless, as an administrator, work actively to develop a department consensus on major issues whenever possible. Hold regular staff meetings. On a personal level, try to be fair, be consistent, be honest, be ‘above board’ and be a ‘straight shooter’. Finally, when placed in an administrative position, develop an exit strategy for the time when the job is completed. Most medical administrative positions, academic or otherwise, last for a finite period. Plan accordingly before you step down. When the medical work is over, no one is going to remember whether you attended a particular meeting on a particular date, worked on a specific committee or whether a talk you gave 20 years ago was the wonderful performance you thought it was. Your family, however, will remember your holidays, all the trips and the attention you gave them. Those memories are what remain when your medical practice and all that it entails is finally finished. Don’t neglect your family. Put them first and keep them there consistently, in spite of the many ongoing pressures to do things differently. Your family is the constant in your life. Take care of it. Dave has been on the Pediatric Faculty at the University of British Columbia (Vancouver, British Columbia) for 39 years. Responsible for the General Pediatric Clinic at BC Children’s Hospital (Vancouver, British Columbia), he was also the first Medical Director of Emergency. He’s worked as a general practitioner, a child abuse specialist and an oncologist. He is the Past President of the Canadian Paediatric Society and a former Board Member of the British Columbia Medical Association, heading Health Promotion. Dave married Claudia 40 years ago and is the proud father of three sons and a daughter. Grandchildren are anticipated.

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