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Doctor and Parents Should Have Mutual Trust

By Lance Chilton
For the Journal
Q: I know doctors don't do house calls anymore. So what can my daughter expect from her child's new doctor?
    A: You're right. Most of us don't make many house calls any more. It just isn't a very efficient use of our time. In addition, many of our patients will need something we can't readily carry with us: a lab test, an X-ray, an immunization.
    I occasionally offer to make a home visit when I think either a child or a parent is unduly uncomfortable in my office: the 3-year-old who screams the moment I enter the room, or the parent who just seems to freeze in that unfamiliar setting.
    That said, there are some expectations of a child's doctor that are still quite reasonable. Doctors speak of the components of what they offer to children as making up a "medical home," a place where all medical needs can be met.
    The American Academy of Pediatrics defines a medical home as one that is "accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective."
    Accessibility is the key to making everything else work. One needs to be able to reach the office; otherwise the doors to the medical home are locked. Can your daughter get through on the phone to the office staff, or is she on hold for enough time to feed her baby twice? Do trained office staff give good advice in a timely manner, and can she talk with the doctor within a few hours if she's not satisfied with the answer she gets from staff? Are arrangements made for advice and emergency help 24/7/365, or is she thrown on the tender mercies of the emergency room? That's the "continuous" part.
    Can your grandchild's doctor provide or arrange comprehensively for all the care needed? Pediatricians and family physicians still provide a much larger proportion of the care required by children than those who care for adults, who rely much more on specialists.
    But specialists are needed sometimes for children. You want your grandchild's doctor to refer only when needed and always when needed— not for a cold or an ear infection, always when he's not sure what to do for a heart problem or a broken bone. You want these referrals to be made in a coordinated fashion, by a doctor who maintains an interest in the result.
    Children exist in a family, not in isolation. Your grandchild will be affected if your daughter is depressed or if your son-in-law is drinking or if a sibling is ill. The doctor needs to recognize these problems and to deal with them.
    "Compassionate" and "culturally effective" go together. Your doctor and your grandchild's doctor need to know and care where you're coming from in order to meet you there. She or he needs to be able to feel what you feel to be able to counsel effectively. In my opinion, the doctor needs to realize that she/he is an adviser, not a decider, and to inform you about what she/he believes is best for your child.
    Everyone— especially those who have ongoing medical problems— needs a medical home with each of these components. I hope your grandchild doesn't ever have severe problems, but if she develops them, you want her to get the best possible care. Don't choose a doctor using a dart and dartboard.
    You didn't ask, but I'll briefly answer the question, "What should the doctor expect from my daughter?" Most important would be to develop enough mutual trust to allow your daughter to say when she isn't comfortable with recommended care (rather than taking the advice and then not following it). Keeping or rescheduling appointments is a courtesy to the doctor. Not allowing the children to destroy the office is a plus. Bringing a list of questions to ask at visits is always appreciated.
Lance Chilton is a pediatrician who has practiced in Albuquerque for the past 28 years. He is past president of the New Mexico Pediatric Society. Send your questions about children's health to Chilton by mail, Lovelace Pediatrics, 5400 Gibson SE, Albuquerque, N.M. 87108, or by e-mail to lancekathy@yahoo.com.