Time has a question:
Is 10 Minutes Enough for a Well-Child Visit With the Pediatrician?
If only they had called me. I could have told them “no.”
Because I probably spend too much time whinging about the pressures and frustrations of being a physician, I’m going to start out on a different note today. One of the things I absolutely love about the practice where I work now is that all well-child visits are 30 minutes long, and the schedule is set up to protect that time. When I interviewed, my future colleagues were rightfully proud of how the practice genuinely respects the importance of having plenty of time to spend at routine well visits, and it is no lie to say that it was no small factor in my decision to take the job. I know from experience that not all pediatricians are nearly so lucky.
From the article:
Parents, especially brand-new ones, are full of questions. How long should baby sleep? When should he start rolling over, sitting up, cooing? What about naps — when and how often? It would be nice to spend a leisurely hour with the pediatrician, getting all the answers, but one-third of parents say well-visit check-ups last less than 10 minutes, according to new research published Monday in the journal Pediatrics.
Perhaps even more surprising is that just half of those short visits included a developmental assessment, which is frequently the main reason for well-child visits. Most surprising of all, though, is that most parents reported high levels of satisfaction even with an in-and-out doctor visits, indicating either that pediatricians are doing a good job covering a lot of ground in little time or that parents don’t know to expect otherwise.
I am going to assume the best of those pediatricians out there who spend 10 minutes with their patients at well checks, and say that they would almost certainly choose to spend more time if they could. Because there is no way you can really deliver optimal pediatric care in 10 minutes, and I choose to believe most medical providers would want to deliver the best care they can.
Here’s how I do things. Whenever I see anyone for a well check, I begin the visit by letting the parents ask whatever questions they have. Many bring lists, and sometimes seem a little embarrassed or sheepish about bringing them out. When this happens, I point out that answering all of their questions is my job. It’s what I’m expected to do. I also reassure them that when my own son was a newborn there were all kinds of questions that I had, and I’m a pediatrician! Brand new babies are freaky little things, and being a new parent can be very disorienting. It often takes ten minutes or more simply to address all of the parents’ questions, and that’s for babies that are perfectly well. If there’s anything that’s not quite right, it obviously takes more time.
Even for healthy older children, there are all kinds of questions that I ask that easily take ten minutes or more. I ask how school is going. I ask how they get along with other kids, and if anyone is giving them a hard time. I ask about their eating habits, and if they get any exercise. I ask what they like to do for fun. And then there are all the additional questions I ask my adolescent patients during the confidential portions of their exams. I ask these questions for every single one of my patients, and I couldn’t possibly feel like I was doing my job well if I didn’t.
Not surprisingly, parents reported less “family-centered” care and fewer preventive-care discussions during the shorter visits. There’s a huge push in medical care to emphasize prevention — teaching kids to exercise and eat well when they’re young, for example, rather than waiting until adolescence to treat obesity — but the Pediatrics research shows that demands on physicians’ time are restricting their ability to emphasize preventive care or delve into dicier topics.
The article reports that most of the parents whose visits are short feel that their questions are answered, and that’s not nothing. But it’s also not the best they could be getting. In addition to all the information we give regarding questions parents already have, there’s all the information we give about preventive care. This is typically referred to as “anticipatory guidance.” It’s something I know my patients should be getting, but parents may not know to expect it.
For example, if I’m seeing a two-month-old I’ll ask to make sure she’s doing the things a two-month old should be doing. But I’ll also talk to the parents about the things they can expect between now and the next visit. I’ll advise them that their child might learn to roll over, so it’s important not to leave her unattended on flat surfaces. I’ll talk about things they can do to foster motor development. For older kids, I try to tailor the anticipatory guidance to their particular situation. For kids who are in contact sports, I’ll talk about taking concussions seriously. I’ll talk to my teenagers about body image. You get the idea. If all I were to have was ten minutes, you can bet all of that would get the axe.
The actual physical examination itself can easily be done within ten minutes. However, the more rushed you are, the more cursory your exam can get. I can think of a few very serious conditions that my colleagues and I have found in the course of a routine physical exam, which we might have missed or glossed over if we’d been in and out. Missing serious diagnoses is one of those things that gives me a cold sweat in the middle of the night, and it can happen to anyone. But being able to perform a methodical, unhurried exam certainly makes it less likely.
As I’ve already said, I’m sure that most pediatricians who do spend only 10 minutes with their patients for well visits are doing so because of financial realities. One of the big changes I hope to see eventually with our healthcare policy is in how we compensate medical providers. Payment is inordinately shifted toward specialized, procedure-based care. Paying more for the care that keeps us healthy rather than fixing us when we’re broken would allow physicians to spend the time they should with their patients. Short-changing patients with rapid-fire well checks gives the appearance of preventive care, and puts a check mark in a box rather than giving patients the attention they really deserve.
I think of well-child visits much like my opening visit with a new member of the faculty.
You want some time to chat. People’s contexts are important, there’s a lot of implicit going on in the communication they’re sending your way… and until you grok their center in the universe, your implicit + their implicit leads to “Wait, you want… what?” six months down the line.
I went to two practices before my current one, both of which had 10 minute well child visits. (Usually after a wait of 30 minutes to two hours in the waiting room.) It felt rushed and careless and disrespectful. My minor concerns didn’t get aired. Certainly developmental issues, sleep issues, etc. were not touched. No one remembered us when we returned for another visit.
In my current amazing practice, we get 30 minutes for a well visit for my typical kid, one hour for a well visit for my special needs kid. They get to know my kids which makes them more comfortable and less likely to freak. They also remember my kids, which helps a lot when I bring them in for sick visit (both have stoic temperaments (not from my side!), and it’s kind of subtle when they are not right). They know me, which means they know I want a certain level of explanation. It turns us from an item on a to-do list to a relationship.
In short, I agree. Very important!