Pediatric patients present a special challenge that, when poorly managed, can be stressful, disrupt patient flow and induce tinnitus. However, pediatric patients also present an opportunity to impact a life at an age where small improvements can yield huge benefits over a lifetime. With the right methods, pediatric exams can be enjoyable and effective. Here are four ways better preparation can improve your exams.
1. Plan ahead. There is a limited amount of time most pediatric patients can tolerate the clinic before they decompensate. Imagine the patient has an internal countdown timer, like the stereotyped bomb in a movie, which starts ticking when he or she enters the clinic. When the timer reaches 00:00, the child explodes, figuratively, and the exam is over.
Plan ahead to perform an excellent exam before the bomb blows. Review the patient’s history and complaints before entering his or her room. Then check that the exam room has the appropriate equipment. Divide the exam elements into categories:
- Must: Elements that you have to get in order to appropriately manage the patient.
- Intend: Elements you expect to get, but which are not mission-critical in management of the patient.
- Like: Elements that would be nice to get, as a matter of being thorough, but are unlikely to change your medical decision-making.
2. “Suit up.” I universally wear a suit. It subdues white coat-associated fears and lets me maintain a presence of authority and professionalism for the parents, even when acting a bit silly with the patients. More than just decoration, think of the suit jacket as a tactical vest. I pack the pockets carefully each morning, keeping useful tools accessible for an efficient exam. My jacket is stocked with the following items:
- Illuminating fixation toy without noise maker
- Illuminating fixation toy with noise maker
- Magic trick du jour, which sometimes doubles as an illuminating fixation object
- 10PD prism, for fixation preference testing
- 28D lens
- 90D lens
- Earplugs: parents are not offended when you protect your hearing
- “Gold” coins or stickers for patient rewards
- Pen
- Business cards
3. Help your staff help you. Just as some physicians fear pediatric exams, many medical assistants are also uncomfortable preparing pediatric patients for the physician. Too often, the result is that the medical assistant completes essentially no workup (no history, no vision, etc.). Alternatively, the assistant may upset the patient by failing to adapt to his or her needs, making the subsequent physician exam unnecessarily difficult.
Help your staff help you by teaching them how to better manage children. Share some of these pearls with your assistants. Let them watch you manage a difficult child. In time, your assistants can become as essential to a successful pediatric exam as they already are for a cataract evaluation.
4. Set the tone: this is your chance to be the “fun doctor.” Enter the room with energy and enthusiasm. I immediately solicit a high five from the patient, any siblings in the room and then shake the parent’s hand (or high five the parent, if they initiate it).
Next, elevate the child’s chair and/or lower the exam stool, so that you seem smaller to the patient. It is helpful to add a flavor of magic early in the exam. Inquire about “close up magic” at your local magic store. Fortunately, most children are entertained by magic, even when poorly executed (no pyrotechnics needed).
If you need additional history to steer the exam, directly address the child. Most parents are quick to fill-in gaps and inaccuracies in the child’s story. Addressing the patient, not the parent, allows me to observe the patient and begin the exam while simultaneously collecting additional history.
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Next time: 5 pearls for conducting a better pediatric exam
For further reading, I recommend Clinical Pearls for Pediatric Ophthalmology by Aaron Miller, MD.
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About the author: Chris O’Brien, MD, MBA, practices both pediatric and comprehensive ophthalmology at Center For Sight, in Knoxville, Tenn. He joined the YO Committee in 2014. He is an alumnus of the Washington University economics program and is the only graduate to concurrently receive MD, MBA and MPH degrees from Tulane. Dr. O’Brien served as chief resident at New York Medical College and completed a fellowship in pediatric ophthalmology at the University of California San Diego’s Shiley Eye Center and Naval Medical Center San Diego.